Laserfiche WebLink
S R z i <br />V ■ ivhonnwit-d Health <br />■.'.'.ons 1 and 2. If vour commissarv is located outside of San Joaouin County also complete section d. <br /> <br />ZJ <br />Date-.nature. <br />Date3EHS Signature. <br />'G3 f. Hazelton Avenue I Stockton. California 952U5 | T 209 -168-3420 | F 209 464-0138 | v/A’W.sjgov.oni'ehil <br />.-oiness Name <br />'.enOoerator Name <br />Electrical hook-ups <br />ES Toilet and handwashing <br />21 Potable water <br />tX Vehicle wash <br />FA# <br />7,0^-TA /- / l/faS <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />22 completed by APPLICANT <br />J2. <br />C/; <br />Commissary Name California Catering Food Service & Supply <br />Address 2440 S. Airport Way Bus. Phone <br />u.v Stockton Zip 95206 Owner/Operator Reyes Rubio <br />ail aopropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />I lot & Cold water for cleaning <br />0 Store dry^od/supplies <br />___________________________ <br />-rreci to me best of mv knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />^mmissarv owner snail notify the EHD immediately. <br /> _________ _____________________________ I s <br />3?! obe completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. | <br />The commissary is located in __ __________________County. The above food facility meets the <br />'■nmmissary requirements in California Health & Safety Code. The above checked services are available at the <br />•move commissary. Please notify EHD If the status of their operating permit changes. <br />OMMISSARY AGREEMENT <br />"•?e Food Facility * Caterer <br />SAN IOAOUIN <br />v v 2 8 Q O <br />3-compartment sink <br />7^ Food preparation <br />E| Store refrigerated food <br />Overnight parking <br />. nereby stale that the information I have provided is current, true and <br />y <br />-Cfryi__________1—_____________ <br /> . ;.-.t=ss Madina Address Ifo6// <br />1 -v 4^-/Fj (cp State(g Zip 45 Bus. Ph.: ■■■ <br />I. . hereby slate that the above information is current, true and correc* <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California Hes’i.’; <br />Safety Code, and San Joaquin County Environmental Health Deoartment (EHD) reouirements. If the use *hn <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in p^rr.> t <br />revocation and oenah^ <br />Signsrj-:. ' <br />lic. Plate # 4 v