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!A{ QUIN Environmental Health Department <br /> MII Greatnessgrowshere. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections f and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> Business Name Island Shaved Ice Lic. Plate# 4LK1202 <br /> Owner/Operator Name Stacey Panyasee, Peter Panyasee <br /> Business Mailing Address 2130 S Sutter St <br /> City Stockton State_Zip <br /> CA 95206 Bus. Ph.209-684-6705 Alt. Ph.209-981-0091 <br /> 1,Stacey Panyasee , 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 discon ' ed,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a p alts <br /> SignatureDate <br /> Commissary Name California Catering Truck Wash FA# Q <br /> Address730 S California St Bus. Phone 209-464-9707 <br /> City Stockton Zip 95203 Owner/Operator <br /> Check all appropriate services provided: � S <br /> wastewater disposal rd 3 compartment sink Q Electrical hook-ups <br /> lid waste disposal Food preparation Ef"Toilet and handwashing <br /> Hot&Cold water for cleaning GMtore refrigerated food �le water <br /> C� S ore dry ood/supplies Overnight parking Vehicle wash <br /> 1, A Y �, /� hereby state that the information I have provided is current,true and <br /> correct to the best of my know dge,an meets the California Health&Safety Code requirements. If the food facil[it <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary er shallotify the EHDimm ' telly. � Q <br /> Signature II �A �� 'OAtV l Data <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 at1he <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />