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<br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />Orit1MISSARY AGREEMENT <br />"9 Food Facility Caterer <br />sections 7 and 2. If your commissary is located outside of San Joaquin County also complete section <br />comoieted by APPLICANT <br />ness Name C1 y ici veia.zs () c C Lic. Plate # <br />-nruDerator Name Toi1 11 Yi4 Tiq AA iii A <br />i::ess rvlaliina Address 37.6 j/j/ FIC.4111,0 <br />r.:t.yr5/(7( State c ) zit) pt QS Bus. P117,0 )/ : <br />I. . hereby state that the above information is current, true and corrcct <br />the best of my knowledge and agree to utilize my aoproyed commissary in accordance with Californi He <br />Safety Code. and San Joaquin County Environmental Health Department (END) requirements. It the use OT (P <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this ottice may result in pen. , <br />revocation aria oenaiti <br />Sig <br /> <br />r <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name California Catering Food Service & Supply FA# <br />Address 2440 S. Airport Way <br />.:ti Stockton Zip 95206 <br />appropriate services provided: <br /> <br />Bus. Phone 2C2Ci- <br /> <br />Owner/Operator Reyes Rubio <br /> <br />itr Wastewater disposal <br /> <br />Or3-compartment sink <br /> iv' Electrical hook-uos <br />fa- Solid waste disposal <br /> ip Food preparation <br /> 6' Toilet and handwashing <br />i!ct & Cold water for cleaning <br /> <br />MI Store refrigerated food <br /> a) Potable water <br />a Store dry food/supplies <br /> IX1 Overnight parking <br /> <br />tir Vehicle wash <br />0 -- .7-iereby state that the information I have provided is current, true and <br />—.y:srect to the west of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />.:oerator tails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />—7iEsary owner snail notify the EHD immediately. <br />,. io be completed by the ENV HEALTH jurisdiction outside of San Joaquin Col <br />The commissary is located in County. The above food facility meets the <br />rommissary 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 />'.REFIS Signature Date <br />Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sigov.orgtend <br />?k 25 00 2,001 <br />Date t(i. I I 17 Li