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SAN JOAQUIN <br /> Environmental Health Departmrxit <br />'3MMISSARY AGREEMENT <br />Food Facility Caterer <br />. and 2. if your commissary is located outside of San Joaquin County &so complete section <br />compieted by APPLICANT <br />Name 4- 56(2 tv ch(i. Lie. Plate ft 2E 15' bi t 4 5 <br />-nr.Cmerator Name R oi ly li tekte <br />rvlaiiina Address z6 ()D i 1- e <br />.•..).0c 14-on State(A Zio i) 6.; Bus. Ph. hcr)._ <br /> . hereby state that the above information is current. true and (=cc': <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Haalq - <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) reauirements. If the use OT In-- <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in per;. <br />revocation and pen J. <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 I L, -.7_ 5 /- <br />Stockton Zip 95206 Owner/Operator Reyes Rubio <br /> <br />appropriate services provided: <br />.^/astewater disposal Or 3-compartment sink ef Electrical hook-ups <br />X Solid waste disposal el Food preparation hit- Toilet and handwashing <br />X :3t & Cold water for cleaning lki Store refrigerated food 20 Potable water <br />)1 Store dry food/supplies IN Overnight parking gi Vehicle wash <br /> <br />e ,-,t, C---, ,i to ia . nereby state that the information I have provided is current, true and <br />--.;rrect to the btrst 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 />sary owner snail notify the EHD immediately. . <br /> <br />7.--- r <br />.:7!ature Date /18/2 <br />Tu be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. 1 <br />The commissary is located in County. The above food facility meets the <br />rr)rnmissary requirements in California Health & Safety Code. The above checked services are available at the <br />Above commissary. Please notify EFID if the status of their operating permit changes. <br />RENS Signature Date <br />. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I wwv...sIciov.orglehd <br />csy D-0(1