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r <br /> t <br /> S A N J OAQ U I N Filrivir•s7nmental Health Department <br /> -MMISSARY AGREEMENT <br /> ~ood Facility Caterer <br /> -:tons 7 and 2. If vour commrssary is located outside of San Joaquin County also complete section j. <br /> COMMeted by APPLICANT 1 <br /> _,.-jtness Name _ Ka N —'(Y1 t1� L <br /> uc. elate# �gSw <br /> ':'!erruoerator Name rVIVR A L_\ MflNfl lv' kLt7"TN A- <br /> :::ess rv7aiiina Address .ySS'G •p 'Ili laft iv STtl <br /> Nft�64 State CA Zip �LJ23ZBus. Ph.Y23116 41—S*7 rPh. . .,. <br /> L-A 'It H A 1' V 07 tA A .herebv state that the above information is current. true and correct is <br /> the best of my knowledge and agree to utilize my aooroved commrssary in accordance with California Hpnlli, <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. It the use of rni! <br /> commissary is discontinued. the permit holder must notifv the EHD. Failure to notifv this office may resuwt in perm., <br /> revocation and oenam, I S!gnatu, <br /> _2. To be completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name California Catering Food Service & Supply _FA# <br /> Hddress 2440 S. Airport Way Bus. Phone <br /> Stockton _ Zip 95206 Owner/Operator Reyes Rubio <br /> - : ii aooropriate services provided: <br /> 0 :"lastewaler disposal -.0 3-compartment sink Electrical hook-ups <br /> ' <br /> Solid waste disposal Li Food preparation Toilet and handwash rig <br /> Cold water for cleaning Store refrigerated food Potable water <br /> CI Store dry food/supplies L Overnight parking Vehicle wash <br /> -� .. I = <br /> nereby stale that the information I have provided is current, true and <br /> --rect to the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> aerator fads to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> ^ —!ssary owner snail notify the EHD immediately. <br /> -~3ture Date <br /> �._T v be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br /> Tne commrssary is located in County. The above food facility meets the <br /> ;'nmmissary reauirements in California Health & Safety Code. The above checked services are available at the <br /> -:cove commrssarv. Please notify EHD if the status of their operating permit changes. <br /> -zEHS Signature Date <br /> _ HaMton Avenue I Stockton,California 952051 T 209 468-34201 F 209 46"138 1 vnvvasjgov.ori; , is <br />