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SAN JOAQUIN Environmental Health Depar'l r.—,I-lt <br /> ''MMISSARY AGREEMENT <br /> :te Food Facilitv .., Caterer <br /> _z1:ons i and 2. if vourcommissary is located outside of San Joaquin Counly also Complete sr:ctron <br /> :omcieted by APPLICANT <br /> _'-6Li ieSS iVame inp i A Lie.Plate# <br /> ,e!%­)rierator!Name J7e ( Sift1clo <br /> maiiina Address 2 7y f Cohs Dr __ <br /> 9I teir k State zip--7�' 7_Bus. Ph.___�0�.-�JG' <br /> I, herebv state that the above information is current. true and correct fn <br /> the best of my knowledge and agree to utilize my ap'proved commissary in accordance with Calirornia Heai3t' <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD! reouirements_ If the use ^f thn <br /> commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may resuir in per„,., <br /> revocation and ae _. -7 Z <br /> Signw::-' - r• �-�7 <br /> ' 2.To a comole#ed b- COIUINlFSSARY OWNERIOPERATOR <br /> Commissary Name California Catering Food Service & Supply _FA# <br /> Address 2440 S. Airport Way Bus. Phoned L' <br /> 1,,v Stockton Zip 95206 Owner/Operator Reyes Rubio _ <br /> - aii appropriate services provided: <br /> Wastewater disposal W3-compartment sink "Aff Electrical hook-ups <br /> i� Solid waste disposal 14 Food preparation 1W Toilet and handwashing <br /> f4 i & Cold water 1oi cleaning 10 Store refrigerated food Potable water <br /> Stare dr food/supplies . 14 Overnight parking Vehicle wash <br /> nereby stale that the information I have provided is current, true and <br /> -_"act ro the bes of my knowledge,and meets the Califomia 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 /> :Tmissary owner snail notify the EHD immediately. /Z'-4 <br /> -c;riafure ~ � Date <br /> 3. To be completed b e?E _ CT '(idsd'cgon�4 t&of San Joa uin Co. <br /> The commissar 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 Oate <br /> r,(�E_ HazPlton Avenue-I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 l <br />