Laserfiche WebLink
i <br /> Fi201103zZ[ <br /> SAN JOAQUIN Fnvirom.-nontai Health <br /> 0MMISSARY AGREEMENT <br /> ife Food Facilitv Caterer <br /> .ceci�ons i aria 2. if vour comrnissary is located outside of San Joaquin County also complete sect, n <br /> COMMetsd by APPLICANT - <br /> -- - ---- <br /> "SdIess ivame [�_ rcc s T r`u ��rv�-1L uc.Plate# d <br /> er:unerator Name 11L. W 0 c&&Y1cov-e- dY <br /> ::ass Mailino Address r •.�ir^ � �C�� tit <br /> StateCA Zip t Bus.Ph.16 +st -5 �-3 ;,`: . . . ��lSl� <br /> 1, herebv state that the above information is current.true and correct er, <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California_ Hf-air. <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) reouirements. If the use of the <br /> commissary is discontinued,th4ermit holder must notify the EHD. Failure to notify this office may result in perm-, <br /> revocation and penal=.=� <br /> 2. To be complete y COMMISSARY OWNERIOPERATOR . __ _ _- _- <br /> Commissary Name California Catering Food Service & Supply FA# <br /> Address 2440 S. Airport Way Bus. PhoneZe-, V1 6 <br /> ai v Stockton Zip 95206 Owner/Operator Reyes Rubio <br /> -i:aii appropriate services provided: <br /> Wastewater disposal W3-compartment sink Rf Electrical hook-ups <br /> 14 Solid waste disposal 6 Food preparation !r Toilet and handwashmg <br /> q I;ot& Cold water for cleaning El Store refrigerated food Potable water <br /> Store dry food/supplies , 11 Overnight parking M/Vehicle wash <br /> ,e— 2,bi 0 ,r►ereby state that the information I have provided is current,true and <br /> --. erect to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> ;perator fads to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> _rrrrssary owner snail notify the EHD immediately. <br /> ::.nature r Oate 17i j 1 Z <br /> 3. To be,r.mplawd,bY: T sldiQW 4WIde-of sen Joaquin Co. <br /> 'The commissary is located in County. The above food facility meets the <br /> rnmmissary 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 /> :"a`i F. Hazelton Avenue I Stockton,California 952051 T 2.09 468-34201 F 209 464-0138 1 tuf <br />