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Environmental Health ris;partfrow,.. <br />3MMISSARY AGREEMENT <br />'7qe Food Facility Caterer <br />Cia)17S I and 2. If your commissary is located outside of San Joaquin County also complete section <br />-;:com.otetect by APPLICANT <br />.iess Name --4-c-o& F_Z--1.; c 0 / 1 (1./. Lic. Plate # <br />ii2c) /471 PditiC <br />:::i;e.,:is Maui a Address jo <br />:,:11, SfO 1 • 11 State69- Zio 95(13 BUS. P11.0 )/6•- PS- / f.,.-t. t .:_sc)- 3.3. -66 g <br />I. '-) <br />/ <br />IY3 i d 1-7 / P c V t- - . hereby state that the above information is current, true aria come::: ...,.,) ,,. <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California HeAlqt , <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) reauirements. If me use of Jim: <br />commissary is discontinued, the permit holder must notify the EFID. Failure to notify this office may result in oem,,, <br />revocation E.--,.. anti pen <br />Signatum <br /> <br />6 -Jt1 <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name California Catering Food Service & Supply FA# <br />Address 2440 S. Airport Way Bus, Phone 1 0/- rt /— /96 <br />:AY Stockton Zip 95206 Owner/Operator Reyes Rubio <br />au i appropriate services provided: <br />O 3-compartment sink <br /> la Electrical hook-ups <br />6 Food preparation <br /> fri Toilet and handwashing <br />16 Store refrigerated food <br /> <br />al Potable water <br />Overnight parking <br /> El Vehicle wash <br />, nereby state that the information I have provided is current, true and <br />--..,rrect 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 /> <br />i::;riature <br />!...mrhissary owner snail notify the EHD immediately. <br /> Date /IC /z <br />To be completed by the;ENV.MEALTHiUtisdiction outeide-ofSan JoaqUin Co. <br />The commissary is located in County. The above food facility meets the <br />ro.mmissary 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 />RENS Signature Date <br />Hazeltan Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.siclov,orcifeW <br />PkOlo25L0-± <br />-eriOnerator Name <br />L9B3,_C.9 c ) <br />I Wastewater disposal <br />Solid waste disposal <br />& Cold water for cleaning <br />54 Store dry food/supplies <br />S t