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FQ01 %6210 <br /> e� f 1<aiviromnentai Health <br /> `OMMISSARY AGREEMENT <br /> .tie food Facility o Caterer <br /> sections i and 2. If vour commissary is located outside of San Joaquin County also complete section . <br /> 43-a COITIDFeted byAPPLICANT _.4 <br /> ._";sinress Name [Nj cCc, T0,Cp i_ic.Plate# b <br /> erivoerator Name 1102 W 0 Cl, <br /> 4ss Mailina Address 'ruc <br /> "-;ySc,�- State CA-ZiD o Bus.Ph.6 s L131 -5 �-� ;,� . . . . l� 6 C s 3 <br /> i, herebv 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 Hppiffn, ' <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of!he <br /> commissary is discontinued,tfe�,Ipermit holder must notify the EHD. Failure to notify this office may result in peri,,.; <br /> revocation and penalt <br /> To be cOMOW e y COMMISSARY; W.NMOPERATOR'.. <br /> Commissary Name California Catering Food Service & Supply -FA# <br /> address 2440 S. Airport Way Bus. Phone 7v V1 6 . <br /> Fav Stockton Zip 96206 Owner/Operator Reyes Rubio <br /> ail appropriate services provided: <br /> g Wastewater disposal 1W3-compartment sink 10 Electrical hook-ups <br /> 14 Solid waste disposal 1� Food preparation OP Toilet and handwashing <br /> Hot&Cold water for eleaning 11 Store refrigerated food 6(Potable water <br /> Store dry food/supplies Overnight parking Vehicle wash. <br /> nereby state that the information I have provided is current,true and <br /> arect io the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> Aerator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> _=,,r;ssary owner shall notify the EHD immediately. <br /> .:;mature r~ Date <br /> 3. To'De comp.IBM dbYa#j R i us I i I I WNW W,11 0, 6-01 ide`of fan Joa um Go.. <br /> '=he commissary is located in County. The above food facility meets the <br /> rnmmtssary 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 Dale <br /> -68 E- Hazelton Avenue I Stockton,California 952051 T 209 468-3420 1 F 209 464-0138 4vti��v ,igov,grt,'�:tut <br />