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_pMMISSARY AGREEMENT <br />e Food Facility Caterer <br />......... I and 2. If your commissary is located outside of San Joaquin County also complete section <br />:completed. by APPLICANT <br />...zsiness Name 1.; 't,n (2,1'\09) b-11/10,--rd_ k. CC_ Lic. Plate tt. <br />....s...riCiperator Name ilWoc -t k1:), DATA) <br />ss rviailina Address 3D 26 <br />56: LA-c,". Statdqk Zit) ciczi,) Bus. Ph `:--)q) 1-111-0513P4:. • 04 - D-1- <br /> . hereby state that the above information is current. true and correc: <br />the best of y knowledge and agree to utilize my apbroved commissary in accordance with California FlePm-, ' <br />Safety Code. and San Joaquin County Environmental Health Department (EHD) reauirements. If me use 07 <br />commissary is discontinued, the petmit holder must notify the EHD. Failure to notify this office may result in nem, <br />revocation and peiiac <br />Signature:: / / z <br /> <br />2. To bil•CoMialeted by. COMMISSARY OWNER/OPERATOR <br />Commissary Name California Catering Food Service & Supply FA# <br />Address 2440 S. Airport Way Bus. Phone 2-0 c7 - SarN6? <br />iv Stockton Zip 95206 Owner/Operator Reyes Rubio <br />au i appropriate services provided: <br />k Wastewater disposal ti 3-compartment sink ti Electrical hook-ups <br />lc Solid waste disposal et Food preparation ea Toilet and handwashing <br />& Cold water for caning id Store refrigerated food IN-Potable water <br />4(0_7 dry food/suppli8 Overnight parking XI-Vehicle wash <br />-k)b cc nereby state that the information I have provided is current, true and <br />-T.rrect to thnest 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 />nrnissary owner snail notify the EHD 1r:1:media <br />inature Date <br />To be completed by the:ENVMEALTH jUtisdiction outside of San Joaquin Co. <br />The commissary is located in County. The above food facility meets the <br />rrnmissary requirements in California Health & Safety Code. The above checked services are available at the <br />:4bove commissary. Please notify EHD if the status of their operating permit changes. <br />REHS Signature Date <br />E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sinov,omfoll,i <br />f2g.200) RD