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.ness Name EA.(' t X4tf4 T&coC•- <br />oseloio EAsotA ?no.c.49 riOnerator Name <br />Lic. Plate ft <br />SAN JOAQUIN wironmental Health 1,v. <br />P21 ti)ql <br />7JMMISSARY AGREEMENT <br />te Food Facility Caterer <br />7.,..;:;ons -I and 2. If your commissary is located outside of San Joaquin County also complete section <br />completed by APPLICANT <br />:e.ss rviailina Address 3'-%M 1-CA.k otA. <br /> Stat(J Zip S -51- us. Ph. 10-600 -SSD <br />I. LI),S•eic., vx.0 hereby state that the above information is current. true and <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Hellrl <br />Safety Code, and San Joaquin County Environmental Health Department (END) reauirements. it me use 01 <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in nem-, <br />51,2_8/0 <br />revocation aria Denaiti..1-:. <br />Signature Z,1" 127— <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 foci 56/ -f 9c-6 <br />itV Stockton Zip 95206 <br />all appropriate services provided: <br /> <br />Owner/Operator Reyes Rubio <br /> <br />g Wastewater disposal <br /> 3-compartment sink <br />Solid waste disposal <br /> rit Food preparation <br />t t & Cold water for cleaning 4i Store refrigerated food <br />4 Store dry food/supplies 14 Overnight parking <br />P ite \ V,017)i r-) , nereby state that the information I have provided is current, true and <br />-crrect to the bet of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />Iperator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />trr.rnissary owner snail notify the EHD immediately. <br />. To be compietadbythei;l3WAkI3 E,A1MilutietlictiOntigtsicie-DUSan Joaquin Co. 1 <br />The commissary 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 Date <br />E, Hazelton Avenue I Stockton. California 95205 I T 209 468-3420 I F 209 464-0138 I \,v‘wi.siclov.orpleW. <br />Pizt-1003--to <br />ar Electrical hook-ups <br />0 Toilet and handwashing <br />el Potable water <br />Vehicle wash <br />Date S