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‘ SAN JOAQUIN 4 / - COUNTY <br />6reucness 9i(iiY5 e. <br />Environmental Health Department <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 />1. To be completed by APPLICANT <br />Business Name <br /> <br />Lic. Plate # Eno 7 I <br />3 <br /> <br />Owner/Operator Name l'iNc) -M00% in <br />Business Mailing Address C,Cs t Otn Dr. <br />City State State Cy\ Zip ira.lx Bus. Ph. 209 000l 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 penalti <br />Signature <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name f\ ,f1/ CR1I1(1-r F A# <br />Address :ILI E diA)t7P,R. 641/Z_=-- Bus. Phone cw\cr-- <br />City 57-0 Cir r,27 Zip cr ct 5*2-b 5 Owner/Operator _c4 c ; <br />Check all appropriate services provided: <br />Wastewater disposal <br /> <br />CI 3-compartment sink <br /> Electrical hook-ups <br />Solid waste disposal <br /> 0 Food preparation Toilet and handwashing <br />Hot & Cold water for cleaning 0 Store refrigerated food 0 Potable water <br />Store dry food/supplies ------43:, Overnight parking 0 Vehicle wash <br /> hereby state that the information I have provtd is uurre..i.....rn Lrue• bum Ptak 11 GO ICE CREAM <br />correct to the best of my knowledge, and meets the California Health & Safety Code req i.34162tE.IfIVIIKwedWE. <br />operator fails to comply with the conditions of this agreement, or if this agreement Me KfrOtetrelA , 95205 <br />commissary owner shall notify the EHD immediately. i <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 Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I vvww.sjgov.org/ehd <br />1, <br />Date 2-• g <br />Date 0-