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SAN JOAQUIN <br /> <br />Ftwironmental Health Department <br />MMISSARY AGREEMENT <br />Food Facility Caterer <br />:F.,-lions 7 and 2. If your commissary is located outside of San Joaquin County also complete section j. <br />compieted by APPLICANT _ <br />....wness Name - —DithR LIP. Plate # c le-S-6, 03_ <br /> <br />!.#.3..riCkierator Name MOP MD lin i%; 1407 Itt- <br />rvia Adct ress SSD Q11J &11. <br />' • Orlik Ci4 State Citb. Zip tr v-42,7 Bus. Ph. Y23---16'l—Srsi !-.J. <br />RAO 41-1-4 r)-(1-1a. hereby state that the above information is current, true and correct tc <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Hpaiiii - <br />Safety Code. and San Joaquin County Environmental Health Department (EHD' reauirements. It tne use of trill, <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in perm., <br />revocation ana Denaiu <br />Sgnat lu i\t 1 14 4` 42.tr <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name California Catering Food Service & Supply FA#1 <br />Address 2440 S. Airport Wq.y. <br />:v Stockton Zip 95206 <br />73ii appropriate services provided: <br /> <br />Bus. Phone <br /> <br />Owner/Operator Reyes Rubio <br /> <br />0--'."Jastewater disposal <br />3-compartment sink -Er Electrical hook-ups <br />p-Solid waste disposal <br /> <br />di• Food preparation -0 Toilet and handwashinq <br />. t & Cold water for cleaning a'Store refrigerated food <br />Cr Potable water <br />4C3 Store dry food/supplies _. ,..Li Overnight parking .51-Vehicle wash ---) <br />1---e-:, 2.> 12- \) ,i1 I C ) . nereby state that the information I have provided is current, true and <br />- --.rrect to thibest of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />;aerator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />rnssary owner snail notify the END immediately. <br />.3. To 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 />,.r)mmissary requirements in California Health & Safety Code. The above checked services are available at the <br />-move commissary. Please notify EHD if the status of their operating permit changes. <br />;IEHS Signature Date <br />Hazelton Avenue I Stockton, California 95205 T 209 468-3420 I F 209 464-0138 wi.vw,sigov.oro •• <br />L1t tto 212, <br />ih-674 -:nature Date C