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vo sgg312 <br /> S A N J O A U I N Privironmentai Health De partraiEent <br /> 7.'MMISSARY AGREEMENT <br /> .,;p Food Facilitv Caterer <br /> =.!:.ons 1 and 2. If your comrmssary is located outside of San Joaquin County also complete sectmn <br /> r ZiO COMDieted by APPLICANT <br /> r:ess ivame _E/ (Qtgl r1 uc. Plate it <br /> 'er:Ooerator Name -Tes,,S S. F V-LCr t-r ifo So tC 10 - -- _- <br /> =4s wiaiiino Address 75'� Ve- (�,.i ]pr <br /> �t moor km IfState�Zip �5�3�, 7 Bus. Ph. e0%-X1e-fV, <br /> f, hereby state that the above information is current. true and corre&to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Heai+h <br /> Safety Code, and San Joaquin County Environmental Health Department fEHDI requirements. If the use of thr. <br /> commissary is discontinued,the permit holder must notify the EHD. Failure to notify this ottice may result in perr„. <br /> revocation and oe y <br /> 2. To be completed_b COMMISSARY OWNER/OPERATOR i <br /> y. _ __ --- — - -- <br /> Commissary Name California Catering Food Service & Supply FA# <br /> Address 2440 S. Airport Way Bus. Phone i' C: `i 5(, <br /> Stockton Zip 95206 Owner/Operator Reyes Rubio <br /> - 3ii appropriate services provided: <br /> 7( :^Jastewater disposal 14 3-compartment sink "Iff Electrical hook-ups <br /> X Solid waste disposal Vj Food preparation W Toilet and handwashing <br /> & Cold water for cleaning Store refrigerated food Potable water <br /> Store dr food/supplies 1A Overnight parking Vehicle wash <br /> �• �b(o .nereoy state that the information I have provided is current, true and <br /> erect to the bes 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 /> :-^rnissary owner snail notify the EHD immediately. _ <br /> _ mature <br /> ----- Oate -� ZZ /z <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> �mmissary requirements in California Health & Safety Code. The above checked services are available at the <br /> -move commissary. Please notify EHD if the status of their operating permit changes. <br /> PEHS Signature Date <br /> s Hazelton Avenue I Stockton, California 952051 T 209 468-3.120 1 F 209 46-1-0138 1 w=,,.sjgov,orgtvhd <br />