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SAW JOAQUIN <br /> Environmental Health Department <br />COUNTY-- <br />..Y.reatrtes:; groeic <br />COMMISSARY AGREEMENT <br />Mobile Food Facility • Caterer <br />Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />To be completed by APPLICANT <br />Lic. Plate # <br />Owner/Operator Name De.s\f-vAn tAl\11, curh <br />(0 (631 s 'coo e il-A,11 <br />City c -k-11k.)-\--tin StateU_Zip Bus. Ph. Nq--1,1--1)-41 Alt. Ph. <br />, 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 penalties' <br />Date <br />To be completed by COMMISSARY OWNER/OPERATOR PICK N GO ICE CREAI <br />3412 E. MINER AVE. <br />Commissary Name PiCK r1/ c 00--7 FA# STOCK TON, CA 9520! <br />Address Bus. Phone a°c1- WAS)'- Vk <br />City S'T c K r 1r- Zip cp c)! Owkei<TOIDerator <br />Check all appropriate services provided: <br />Wastewater disposal <br /> • 3-compartment sink <br /> 0-Electrical hook-ups <br />El Solid waste disposal <br /> • Food preparation <br /> cVleoilet and handwashing <br />Hot & Cold water for cleaning <br /> 0-"Store refrigerated food <br /> O Potable water <br />Store dry food/supplies <br /> 0.-Overnight parking <br /> O Vehicle wash <br /> , 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 EHD immediately. <br />Signature - , <br />3. to be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />The commissary is located in 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. <br />REHS Signature <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 I F 209 464-0138 I www.sjgov,orgfehd <br />Business Name ()n ei Laarn <br />Business Mailing Address <br />I, 0.64n LAA\V\ orns <br />Signature <br />Date <br />Date