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SAN 'ANN tirfiiv1111Maillta I <br />...7.4.11MISSARY AGREEMENT <br />0°d Facility Caterer <br />Znr--, 7 ana 2. If your commissary is located outside of San Joaquin County also complete section <br />.t cc-moieted by APPLICANT <br />iness Name .DES\ JT Lic. Plate # 2P (43 _ <br />71s5.nOnerator Name Rck..Y..0 \ ‘-.116 <br /> maiiina Address lZ 6:2,00 +-2-VS kg- <br />PlAhlieCcL State CAZio 95317 Bus. Ph. 2P9 G0762,6I.47._ <br />RCVS Fla St iticp1/4 ‘i . hereby state that the above ingAgifin is current, true and correct- <br />the best ot my knowledge and agree to utilize my approved commissary in accordance with California <br />Safety Code. and San Joaquin County Environmental Health Department (EHD) reauirements. If the use ot tn <br />commissary is discontinued, the permit holder must notify the END. Failure to notify this office may result in perm., <br />revocation and oena'T <br />Sigriatizz. S-17 - 26Zt if <br /> <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 <br />iw Stockton Zip 95206 Owner/Operator Reyes Rubio <br />-7 ail appropriate services provided: <br />Wastewater disposal <br />ta 3-compartment sink s r Electrical hook-ups <br />y Solid waste disposal fil Food preparation lid Toilet and handwashing <br />ri J:z...t & Cold water for cleaning fi Store refrigerated food 4- Potable water <br />Store dry food/supplies _ it Overnight parking ri Vehicle wash <br />;. er-S ?AA) -t.. 0 . nereby state that the information I have provided is current, true and <br />rrect to the best 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 />- -.Tnfri:ssary owner shall notify the EHD immediately. <br />--- <br /> <br />_________ - <br /> Date <br />i 0 be 00MPletedtbYMMMIEA1§nntNdkteah*tOdaOffSarfjOaqUin CO. <br />The commissary is located in County. The above food facility meets the <br />erimmissary requirements in California Health & Safety Code. The above checked services are available at tne <br />4bove commissary. Please notify END if the status of their operating permit changes. <br />REHS Signature Date <br />f"-TA E_ Hazelton Avenue I Stockton. California 95205 I T 209 468-34201 F 209 464-0138 I www,sicio.v.orolehil <br />c/i7--lz