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S A N 10A N N E-n irt>'nmentai Health D { <br /> _MM[SSARY AGREEMENT <br /> i"e Food Faciiity .. Caterer <br /> Mr.::ans 7 aria.2. if tour commissary is located outside or Sari Joaquin Courtly also corriprete secrio" <br /> -�r compieted by APPLICANT <br /> —wotass name 94*0� 51G,'-eA - ---�+;.0 L[c.Plate tf - — <br /> :^efiOuerater Name rr� rAAInrl <br /> vss rviai'tina Address (,b 1 0 i'r- <br /> )Uc •-� State -N _Zio �', 2 Bus. Ph.�``t L -� ^ :. . `��1� ° `Zp`'� <br /> I, herebv state that the above information is current,true and correct. . <br /> the best of y knowledge and agree to utilize my approved commissary in accordance with California_ Haairt. <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use oT Vl%• <br /> commissary ss discontinued,the Wmit holder must notify the EHD. Failure to notify this office may result en Derr;, <br /> revocation ana an y 1 <br /> 4 1- <br /> S!gnaturc, <br /> 2, To bll tompleted by.COMMISSARY OWNERIOPERATOR <br /> Commissary Name California Catering-Food Service & Supply FA# 11 ` <br /> Address 2440 S. Airport Way, __Bus. Phone` <br /> �i v Stockton Zip 95206 Owner/Operator Reyes Rubio <br /> aii aeoropriaie services provided: <br /> :Nastewater disposal 10 3-compartment sink 93 Electrical hook-ups <br /> E� Solid waste disposal 6 Food preparation I2 Toilet and handwashing <br /> 0 & Cold water for c ,aning t� Store refrigerated food i r Potable water <br /> 1:1(8tore dry food/supplip� �Overnight parking �f Vehicle wash <br /> v; � _ .K1-e�5 Up- -,Hereby state that the information I have provided is current, true and <br /> -;rrect to the`6est 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 /> ;rn-rnssary owner snail notify the EHD imme4ialely <br /> _ nature Date <br /> i o be 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 /> rr!mmissary requirements in California Health & Safety Code. The above checked services are available at the <br /> :above commissarv. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature [late <br /> 'E'3 F. Hazellon Avenue I Stockton, California 952051 T 209 46B-3420 1 F 209,t6-t-0138 l�v��ti��.sjctay.oral��rsci <br />