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SAN, joAcium <br />—COUNTY— . <br />Greotness grows here. <br />PktSq l-1 130 <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 />To be completed by APPLICANT <br />Business Name I DEAL IcE CREANi\ <br />Owner/Operator Name ZAHID P€P-u <br />Business Mailing Address ?0. 130K 9 54-- <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/panal s. <br />Signature <br /> <br />Date <br /> <br />To be completed by COMMISSARY OWNER/OPERATOR' <br />Commissary Name <br /> \\\ <br />Address 610-e Bus. Phone ,e)cmg, —9ti- <br /> <br />City 9v)elz-k-eN <br /> <br />Zip q c.-2_4)7 Owner/Operator /1tiklila.W\,_ S.- Vi tt <br /> <br />Lic. Plate # <br />City 91C'ekg1C11%) StateOk Zip952-10 Bus. Ph. Alt. Ph. <br />I, oat LA 17-ervt 5 <br />FA# <br />Check all appropriate services provided: <br />113- Wastewater disposal <br />'W-Solid waste disposal <br />'EtHot & Cold water for cleaning <br />CI Store dry food/supplies <br />El 3-compartment sink <br />Food preparation <br />Store refrigerated food <br />'Overnight parking <br />co a <br />IXElectrical hook-ups t 0 <br />1:Croilet and handwashing0 <br />X m G) 0 g 0 z _ <br />O Potable water <br />CI Vehicle wash <br />I, C.+1-A6‘c , hereby state that the information I have provided is current, true <br />correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food fac...y, 0 <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, tp <br />commissary owner shall notify the EHD immediately. IV o • <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 www.sjgov.org/ehd <br />Date —':n- ic Cli