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)<7 Wastewater disposal <br />X Solid waste disposal <br />:3; & Cold water for cleaning <br />Store dy food/supplies <br />14 3-compartment sink <br />14 Food preparation <br />KI Store refrigerated food <br />Overnight parking <br />VOSL1q312 <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />3MMISSARY AGREEMENT <br />-ie Food Facility Caterer <br />7 and 2. If your commissary is located outside of San Joaquin County also complete section 2!. <br />completed by APPLICANT <br />_,.fless Name El (/ te€ vi LIG. Rate ft. <br />-nr:Ocerator Name <br />rvialiina Address 2 7,-/r ,Cv e le Pr <br />v krik State (1 ZiD TS-3(-, I Bus. Ph. <br /> . hereby state that the above information is current true and corre.ci. tci <br />the best of my knowledge and agree to utilize my approved commissary in accordance with California He' <br />Safety Code, and San Joaquin County Environmental Health Department (END) reauirements. If the us^f t <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in peri;„ <br />revocation anci oeoa <br />r._ <br />2, To ISe completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name California Catering Food Service & Supply FA# <br />Bus. Phone — 511 I— /V,t, <br />Owner/Operator Reyes Rubio <br />NEI Electrical hook-ups <br />air Toilet and handwashing <br />MT Potable water <br />0 Vehicle wash <br />7 ' t. <br /> <br />5 b(0 , nereby state that the information I have provided is current, true and <br />--!'!-ect to the bes 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 />.rr.rnissarv owner snail notify the EHD immediately. <br />1..nature <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. 1 <br />The commissary is located in County. The above food facility meets the <br />cnmmissary requirements in California Health & Safety Code. The above checked services are available at the <br />libove commissary. Please notify EHD if the status of their operating permit changes. <br />RENS Signature Date <br />Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I wvimsigov.orglehd <br />(2.1..c(1rirri Sofclo <br />.3 -Z7 2 1 <br />Address 2440 S. Airport Way <br />Stockton Zip 95206 <br />aopropriate services provided: <br />Date