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g <br /> SAN J 0 A Q U ( N Environmental Health Department <br /> COU N T Y <br /> .. oviniveo <br /> -_ <br /> Wbudo <br /> t' 145 . 'Irp <br /> COMMISSARY AGREEMENT TurlV-Ki 9S SQl <br /> Mobile Food Facility * Caterer 2034-2000 <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> rued by APPLICANT <br /> Business Name Cruising Cones 6 Lic. Plate# 4UB4325 <br /> Owner/Operator Name Patricia Hansen <br /> Business mailing Address 11222 Loduca Dr <br /> City Manteca, State CA Zip 95336 Bus. Ph. 209-800-8079 Alt. Ph. 209-993-2461 <br /> Patricia Hansen hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and p Ities. <br /> Signature Date 3"a7 -a O a 3 <br /> meted b , COMMISSARY OWNER/OPERATOR <br /> Commissary Name I V ZVD i S r�06 vm ,�S �i FA# <br /> Address 1 C15 5 � Ki,1 fn�. �� Bus. Phone ('Zoo &3t1- Zdv 0 <br /> Cityy1 d tO f Zip �i'S�W l7 Owner/Operator ✓m� lie G'/1 <br /> Check all appropriate services provided: <br /> B Wastewater disposal 0'3-compartment sink i- Electrical hook-ups <br /> Q' Solid waste disposal ET Food preparation 0 Toilet and handwashing <br /> 0'Hot & Cold water for cleaning E3'Store refrigerated food ®' Potable water <br /> Y! Store dry food/sxqrl <br /> s a Overnight parking O'vehicle wash <br /> 11 <br /> I, , V&7!2 hereby state that the information I have provided is current,true and <br /> correct to the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EUDjaimediibtely. <br /> Signature Date J—dq 7J ZD Z- <br /> 17, <br /> .,_:.. .a.. .. . . . ? ted- by the ENV HEALTH jurisdiction outside of San Ja _„ u,}n.Cow <br /> The commissary is located in Stanislaus County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked services are available at the <br /> above commissary. Please notify EHD if the status of their operating permit changes. r <br /> REHS Signature ' Date t?�j <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />