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SAN JOAQUIN <br /> <br />Environmental. Health Departtnr <br />AMISS ARY AGREEMENT <br />,He Food Facility Caterer <br />- ons I and 2. If your commissary is located outside of San Joaquin County also complete section <br />e completed by APPLICANT <br />Namr-T7Tirc4), 1") Lio. Plate ft 4v v 2. 81D <br />:-er.,,,:inerator Name -t-Vrel, 44 dc <br />Maiiina Address 1409/ <br />(::ty State CC( ZID 531 Bus. Ph. <br />-C_Fr--er) CA 1 7:4 A . hereby state that the above information is current. true and correct <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California FlePt! • <br />Safety Code. and San Joaquin County Environmental Health Department (EHD) reauirements. If the use r‘f the <br />commissary is discontinued, the permit holder must notify the END. Failure to notify this office may resuit in p rm <br />revocation an enaiti-_-. <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name California Catering Food Service & Supply FA# <br />Address 2440 S. Airport Way Bus, Phone E. 9- (c6 /-I 46 <br />Stockton Zip 95206 <br />au i appropriate services provided: <br /> <br />Owner/Operator Reyes Rubio <br /> <br />t Wastewater disposal D'3-compartment sink if Electrical hook-ups <br />)c5i Solid waste disposal 14 Food preparation Et Toilet and handwashing <br />111 !ot, & Cold water for cleaning Store refrigerated food a Potable water <br />gl Store dry,od/supplies al/ Overnight parking t"Vehicle wash <br />, <br />Q-AV , nereby state that the information I have provided is current, true and <br />-7!rect to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />:..nimissary owner snail notify the EHD immediately. <br /> Date /) /z <br />To. be completedbYltteElikAISALTlijcitiSdIdioti buttide..of tan Joaquin CO. <br />The commissary is located in County. The above food facility meets the <br />nmrmssary requirements in California Health & Safety Code, The above checked services are available at the <br />ibove commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature Date <br />F. Hazeiton Avenue l Stockton, California 95205 1 209 468-3420 I F 209 464-0138 I wvo:;.sjnov.ort.Vt,•!ii(1 <br />FR.Vi 002s <br />54- <br />616