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fiJo � rr SW �z <br /> SAN JOAQUIN Environmental Health <br /> -_"IAMISSARY AGREEMENT <br /> ."e Food Facility Caterer <br /> -:".ons i and 2. if your commissary is located outside of San Joaquin Courrf y also cortrp!ete secr+n++ <br /> w'. comoie_rced by APPLICANT - <br /> --ZLI Jess name Lc.elate# 7-1 V 3— <br /> --7r:,jaerator Name M)R A f.-k . ' 1 - <br /> -s, mailina Address D G�'b�► <br /> fYl N71�Cry State Ca Zin�_t3us. <br /> I, f%A0 QW LA K'MA At,__ _ Q ,.herebv state that the above information is current, true and corre <br /> the best of my knowledge and agree to utilize my aooroved commissary in accordanre with Calanrnia HPnl'r <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) reouirements. it the use of in, <br /> commissary is discontinued, the aermit holder must notifv the EHD. Failure to notify this attice may result in pay--.�4 <br /> revocation and oenamat, ` <br /> Signatu„ <br /> 2.To be completed by COMMISSARY OWNERIOPERATOR <br /> I <br /> ommissary Name California Catering Food Service & Su Poly FA# <br /> Address 2440 S. Airport Way Bus. Phone <br /> Stockton Zap 95206 OwnerlOperator Reyes Rubio <br /> aii appropriate services provided: <br /> 42rNastewater disposal .0 3-compartment sink M"Electrical hook-uos <br /> Solid waste disposal r' Food preparation -;8''Toilet and handwashing <br /> & Cold water for cleaning $/Store refrigerated food $Potable water <br /> Z7 Store dry food/supplies _ : -Overnight parking _-CIh7ehicle wash <br /> pit-- e-=� ) ,nereby state that the information I have provided is current, true and <br /> area co the best of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> :perator tads to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> -crn!ssary owner snail notify the EHD immediately, <br /> .^utur [date <br /> -7 C. zzao <br /> be completed by the ENV HEALTH judsditrtion outside of San Joaquin Co. <br /> The commissary is located in County. The above food facility meets the <br /> rgmmissary reouirements 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 Dais <br /> "i F Hazelton Avenue-. I Stockton, California 95205 I T 209 468-342D i F 209 464-013R I v����;.sjg3v.orn!E'-hd <br /> V <br />