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PII.To <br />Date <br />112. To be completed by COMMISSARY OWNER/OPERATOR <br />FA# <br />QI 7^ Martin <br />v___ <br />fet< <br />Date 08/05/25 <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-34201 F 209 464-0138 | www sjgov org/ehd <br />kareem.mohsen@cchealth.org (925) 608-5533 <br /> Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br /> Vehicle wash <br />operator fails to comply with the, <br />commissary ownersf^pptifwfhe <br />Signature / /1 <br />SANJOAOUIN <br />-----COUNTY------ <br />Greotneu growl here. <br />3. To be coifa <br />REC’D <br />AUG 04 2025 <br />Business Name Hirta Hawaiian Shaw Ice <br />Owner/Operator Namejia! <br />Business Mailing Address, <br />City Rrantucwi State Z p Rmnhtrwi <£ip.Bus. Ph.Alt. Ph. <br />I, Martha FUrggiuQt , 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 & r <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 penalties. <br />Signature. <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br /> Overnight parking <br />, 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 />El <br />haRacOTUisl <br />Lie. Plate#. <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />fend 2. If your commissary is located outside of Sen Joaquin County also complete section 3. <br />Environmental Health Department - <br />Stave <br />) CA true <br />J <br />Commissary Name. Atwr rVwDtni^Rry <br />Address. <br />City Irg Z p oarrr <br />Check all appropriate services provided: <br /> Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />I, <br />tions of this agreement, or if this agreement is modified or cancelled, the <br />lately. . <br />_________________Date ________________ <br />ENV HEALTH jurisdiction outside of San Joaquin~Co~] <br />The commissary is located In ^ltra Costa County. The above food facility meets the <br />commissary requirements m 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 <br />________Bus. Phone <br />Owner/Ooerator .^a