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24-1005-4-0 <br />Environmental Health Departrnr!nt <br />..-..)MMISSARY AGREEMENT <br />Food Facility Caterer <br />ThOflS I and 2. If your commissary is located outside of San Joaquin County also complete section <br />completed by APPLICANT <br /> <br />ness Name E.A.c t Zlst c,qtr.ti Lc. Plate if <br />r:Ooerator Name oEA So LA ?e, iALAc2 <br />rviailina Address 34 -Ten\ ( o CA- <br /> Stat(CA Zio S `5"4 (Ails. Ph. iia-czo . <br />I, F vvc hereby state that the above information is current. true anti <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. It me use GT <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in Dem, <br />revocation ano <br />Signaturc, <br /> <br />_2. To be completed by COMMISSARY OWNER/OPERATOR j <br />Commissary Name California Catering Food Service & Supply FA# <br />Socl 56/ - / . VC-6 Address 2440 S. Airport Way Bus. Phone <br />v Stockton Zip 95206 Owner/Operator Reyes Rubio <br />all appropriate services provided: <br />16 Wastewater disposal la 3-compartment sink 151 Electrical hook-ups <br />V Solid waste disposal a4 Food preparation to Toilet and handwashing <br />g !ot & Cold water for cleaning fj Store refrigerated food 6 Potable water .. _, <br />114 Store dry food/supplies . 14 Overnight parking Vehicle wash <br />o :1-( \ "Z),Ini c) . nereby state that the information I have provided is current, true and <br />—.irrect to t e bet 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 />4nature Date /1 S (7 _ V <br />- T.rr.rnissary owner snail notify the EHO immediately. , <br />,.). To be com leteacby thertM14E9LTHIfitiedictiOnbutsidelirSati Joaquin CO. <br />The commissary is located in County. The above food facility meets the <br />r nmmissary requirements in California Health & Safety Code. The above checked services are available at the <br />:4bove commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature Date <br />IL Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.siclo‘.;.mlielo