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)entii' r <br />'3MMISSARY AGREEMENT <br />.'7ste Food Facility Caterer <br />7.E.Cii0r1S I and 2. If your commissary is located outside of San Joaquin County also complete section <br />completed by APPLICANT <br />.riess Name <br />.,.7.erOnerator Name <br />wiallista Address SO4)0(14 S <br />QUA/ StateC4 Zio 9523 Bus. Ph.011 Y6 PS" At .t)2' 3 ' <br />T/7,eid 7V PdV . hereby state that the above information is current. true and correct <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Helift , <br />Safety Code. and San Joaquin County Environmental Health Department (EHD) requirements. If me use pi <br />commissary is discontinued, the permit holder must notify the END. Failure to notify this office may result in DEIT;., <br />revocation and pen <br />Signature A6/d P6we <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br /> <br />Commissary Name California Catering Food Service & Supply FA# <br />Address 2440 S. Airport Way <br />.7,itv Stockton Zip 95206 Owner/Operator Reyes Rubio <br />au i appropriate services provided: <br />fl Wastewater disposal ti 3-compartment sink ig Electrical hook-ups <br />it Solid waste disposal 6 Food preparation rti Toilet and handwashing <br />a i :c)t, & Cold water for-cleaning 16 Store refrigerated food ar Potable water <br />S4 Store dry food/supplies el Overnight parking ig Vehicle wash <br />„ s 'Zito( 0 , nereby state that the information i have provided is current, true and <br />—.:Trect to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />perator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />2:Tr.rnissary owner snail notify the EHO immediately. <br />..i:.;riature ... '.. <br /> Date ZIAC b c/ , <br />' r • • ..• • <br />iu be complete(' by the.F.N1417,1EALTH junsdiction-outsideorSan 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 />qbove commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature Date <br />36 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 www,sloov,orclfehO <br />Pk 0 I ko 25(r± <br />co L. Lic. Plate # <br />P(1416 <br />Bus, Phone 21 , 5-6 / - /Y6 6,