Laserfiche WebLink
SAN'dOAQUIN Environmental Health Department <br /> ,er• t': —COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> jTTj7 d V" RI R ART 5� <br /> o, co,, etedb` APPLI1Aiv� <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 CA Zip 95206 Bus. Ph.209-684-6705 Alt. Ph.209-981-0091 <br /> 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=Z=�� <br /> SignatureDate 1011 1'-W <br /> L. 1',= be comletedb �C ., 'MIS;SAR4Y ®A1N"NrEW®�PE7R�q�TOR. /rn� ' NMII, �/��;t7 (�` ��t <br /> Commissary Name California Catering Truck Wash FA# l lJ " 4 gi-DI <br /> Address 730 S California St Bus. Phone 209-464-9707 <br /> City Stockton zip 95203 Owner/Operator <br /> Check all appropriate services provided: <br /> E Wastewater disposal 0Tcompartment sink El"Electrical hook-ups <br /> p Solid waste disposal O Food preparation toilet and handwashing <br /> IHot&Coldwater for cleaning G�Store refrigerated food O� le water <br /> (� Sore dry ood/supplies 13�Overnight parking Vehicle wash <br /> I, r 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 er shallAlotify the EHD imme ' 1t1enlly,,. "`� <br /> Signature t/v"f/Y�) Date ID 111 D <br /> © ' ecolr leted.�'b'�"�th��e`SEN\"/��H�A�T�H���IStliction,�o'���t�side' nfSan �oa u'�nCC*o <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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />