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SAN JOAQUIN <br /> <br />Environmental Health Department <br />71,11MISSARY AGREEMENT <br />-ie Food Facility Caterer <br />-r4:ct.ons 7 and 2. If your conimissary is located outside of San Joaquin County also complete section 3. <br />. completed by APPLICANT <br />iNiame frc fre5c &fllo biaocth)iLic. Plate it <br />Onerator Name Fif5ydo...62.. 62e4/7._CiiteZ <br />rviaiiind Address I61 -7/17 _St r7.2-05 <br />f:tv S-7terA(-7-64 StatedrZip el--24-Bus. Ph. Z-e3 /**. • <br />1, F 1/691Ny'r* <br />the best of my knowledge and agree to utilize my approved commissary in accordance with Californip Heat! <br />Safety Code. and San Joaquin County Environmental Health Department (END) requirements. If the use "f ?hr. <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in per; <br />revocation anci <br />svnat1:-- 0,-_-)77„( 2 r•-- -"//// <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name California Catering Food Service & Supply FA# <br />Address 2440 S. Airport Way Bus. Phone 7,C2C1 —5-6 / 9L6-4 <br />Stockton Zip 95206 <br />appropriate services provided: <br /> <br />Owner/Operator Reyes Rubio <br /> <br />1c Wastewater disposal <br /> 3-compartment sink <br /> <br />El Electrical hook-ups <br />la Solid waste disposal <br /> Li Food preparation JO Toilet and handwashing <br />61 It & Cold water for cleaning <br />11 Store refrigerated food <br /> <br />El Potable water <br />711- Store dry food/supplies <br /> U- Overnight parking <br /> 0 Vehicle wash <br />( <br />(,› nereby state that the information I have provided is current, true and <br />-7ect to the beIt of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />:perator fails to comply with the conditions of this agreement. or if this agreement is modified or cancelled, the <br />4 /7 <br />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 />rommissary requirements in California Health & Safety Code. The above checked services are available at the <br />=move commissary. Please notify END if the status of their operating permit changes, <br />REHS Signature Date <br />Hazelton Avenue I Stockton, California 95205 I T 209 .468-3420 I F 209 404-0138 kaw...sjciov.orglehd <br />. hereby state that the above information is current true and corre,.- t, <br />missary owner snail notify the EHD immecjigely,„ <br />_ _nature <br /> Date