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S A N 1 OAQ U I N Environmental Health Department <br /> �,AMISSARY AGREEMENT <br /> iP Food Facility Caterer <br /> sec.lxns : and 2. It vour convnissary is locates'outside of San Joaquin County a�so ccmplefe.;ecbnn S. <br /> connoieted by APPLICANT <br /> ii.ess tvame ma f rAC ���� 'S f 1 h 7 uc.Plate - <br /> -sr:ODerator Name <br /> . s rviaiima Address t) <br /> State(�A'Zip E/A Bus. Ph. ��� ��0 fT . , <br /> herebv state that the above information is current.true and correc`t, <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California H—l' <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) reauirements. If the use ^f thn <br /> commissary is discontinued,the permit holder must notify the EHD. Failure to notify this ottice may resuwt in per„. <br /> revocation and Dena:::--. <br /> Z. To be completed_by COMMISSARY OWNERIOPERATOR <br /> Commissary Name California Catering Food SeNice & Supply FA# <br /> Address 2440 S. Airport Way Bus. Phone 7,c�2 <br /> �.� Stockton Zip 95206 Owner/Operator Reyes Rubio <br /> - aii anoropriate services provided: <br /> Wastewater disposal 16 3-compartment sink 0 Electrical hook-ups <br /> t$ Solid waste disposal Lj Food preparation W Toilet and handwashing <br /> Est i:a: & Cold water for cleaning W Store refrigerated food 0 Potable water <br /> 17 Store dry food/supplies Ll Overnight parking Vehicle wash <br /> hereby stale that the information I have provided is current, true and <br /> -rrect to the befit of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> ,:perator fads to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> _mmissary owner snail notify the EHD immed-ijaW <br /> /.Z- Y <br /> _nature Date � Z <br /> -- ---r <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co._I <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 /> HaMtr,n Avenue I Stockton.California 95205 1 T 209 468-3d20 l F 209 464-0138 l wwv..sigov,orgJ�:is�i <br /> F 21�v00 12- <br />