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SAN JOAQUIN E_--nvirontnental Health <br /> IUIMISSARY AGREEMENT <br /> .life Food Facilitv - Caterer <br /> r.;:ons ; and 2. if vour comrnrssary is located outside of San Joaquin County also conlplele s6Cuor <br /> completed by APPLICANT <br /> __swiess Name �� �, c�' lC� i-ic.Plate ft <br /> ,er,OneratorName j����AV, h <br /> :ers Miaiiino Address 66 a <br /> Sx�,c State 's Zip �'�212 Bus. Ph.(:?,—`t Ir 0 3i ' . . . 2�1/ 7 ° '2��� <br /> I, herebv state that the above information is current.true and correc. <br /> the best of F6y knowledge and agree to utilize my approved commissary in accordance with California_ HPa41;l <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of it <br /> commissary is discontinued,the mit holder must notify the EHD. Failure to notify this office may result in Derr;,. <br /> revocation ana a an; <br /> Signature / Z t1 <br /> 2. To b �%ompleted by_COMMISSARY OWNERIOPERATOR __ _ ______ ____ <br /> Commissary Name California Catering Food Service & Supply FA# <br /> Address 2440 S.Airport Way Bus. Phone 70C-7" <br /> iv Stockton Zip 95206 Owner/Operator Reyes Rubio <br /> aii aDoropriate services provided: <br /> Wastewater disposal 110 3-compartment sink 93 Electrical hook-ups <br /> ?Q Solid waste disposal Food preparation M Toilet and handwashmg <br /> 4 i.at& Cold water for c`<;aning i� Store refrigerated food ,tf Potable water <br /> t.)(store dry foodlsupplipxf Overnight parking AT Vehicle wash <br /> Q� ---) )_Ub L n nereby state that the information I have provided is current, true and <br /> �rrect to the est of my knowledge,and meets the California Health&Safety Code requirements. If the food facility <br /> :Nerator fads to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> :rnm;ssary owner snarl notify the EHD irame" <br /> _ ;nature <br /> 3. To be completed by th6'ENY4,1jEALTH jurisdiction outside of San Joaquin Co. <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 cornmissarv. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature Date <br /> -,,?F. Hazelton Avenue I Stockton.California 952051 T 209 468-3420 1 F 209 464-0138 1 <br />