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SAN f OAQUIN Environmental Health Department <br /> — ULiT <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 completedby APPLICANT <br /> Business Name IBMS icE CREWS Lic. Plate# 5?S1';'50 <br /> Owner/Operator Name _Z \1 D1 fl�l V <br /> Business Mailing Address I n 7 <br /> City C-+b StateCAZip Zo Bus. Ph. Alt. Ph. <br /> I, 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 pen ti <br /> Signature Date ( ( f <br /> 2. To be com leted by COMMISSARY�� OWNER/OPERATOR <br /> Commissary Name �� ��� 4S Wd 1JbFK Ful ICE egiOM FA# <br /> Address_&3c WE9ER 4qycNceE Bus. Phone <br /> /26T <br /> � �331sI�{ <br /> City %}Q( Zip q!1 ) OS Owner/Operator t/ a C I-f 6 U'M LJEel <br /> Check all appropriate services provided: <br /> wastewater disposal 121-3-compartment sink 0iE7ectrical hook-ups <br /> ea Solid waste disposal 0 Food preparation Q T61"Iet and handwashing <br /> F� Hot & Cold water for cleaning ;.tore refrigerated foodPotable water <br /> )~ re dry food/supplies f;-Overnight parking i Vehicle wash <br /> 1, le_c4A �� Vt WI 'J , 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 flails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shfll tify the - ��.Date <br /> OZ6 n�Signature G� <br /> 3. To be com leted b the ENV HEALTH tarisdiction 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 /> 1863 E. Hazelton Avenue I Stockton, California 95205 1 T 209 463-3420 1 F 209 464-0138 1 \uvvw.sjgov.org/ehd <br />