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SAN JOHN <br />Environmental Health Departmrmt <br />-::MMISSARY AGREEMENT <br />-.e Food Facility Caterer <br />sectons 1 and 2. If your commissary is located outside of San Joaquin County also complete section <br />comoieteci by APPlitANT <br />'174 c-o,- F./ ---/-(0 4 ( /--/- <br />P B26) /-/ PO x I c .• <br />..1.:-_-:ss rviaiii a Address C eL).0044 S <br />±(-)ie.0,41 StateC4 ZiD ..S2e,3 Bus. Ph„'24;)' Y64. - Yt1 57 <br />I. .‘ f V:7 t (/' g 1,-;), .4.,/(----- . hereby state that the above information is current, true and corm:: <br />the best of my knowledge and agree to utilize my approved commissary in accordance with Californip. i-iel!i• <br />Safety Code. and San Joaquin County Environmental Health Department (EHD1 reautrements. It the use oi <br />commissary is is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in Den:. , <br />revocation ana oen •-.=-.‘. <br />Synatur: <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 L 0 ct /— <br />Stockton Zip 95206 <br />au i appropriate services provided: <br /> <br />Owner/Operator Reyes Rubio <br /> <br />..1.:siness Name <br />-.erOoerator Name <br />Lic. Plate # <br />9,(7 - 3,23. W66g <br />P(r(c <br />of Wastewater disposal <br />I 1 Solid waste disposal <br />ai I :ct & Cold water for cleaning <br />GI Store dry food/supplies <br />?-eAl)e S <br />Date Z /I‘ /Z. c/ <br />112 3-compartment sink <br />th Food preparation <br />Store refrigerated food <br />el Overnight parking <br />fEl Electrical hook-ups <br />fri Toilet and handwashing <br />CT Potable water <br />rif Vehicle wash <br />„-iereby 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 />....-mmissary owner snail notify the EHD immediately. <br />-_:nature <br />Tu be completed by the ENV HEALTH jurisdiction outside of San Joaquin Cod <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 />:4nove commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature Date <br />.7 *.+ Hazellon Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I wmv.sjgov,orgiend <br />-PRoi y 25(A-