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Environmental Health Department <br />^dions 7 and 2. If vour commissary is located outside of San Joaquin County also complete section J. <br />znz]2. To be completed by COMMISSARY OWNER/OPERATOR <br />Date 7 <br />DateREHS Signature. <br />' 268 E. Hazelton Avenue | Stockton. California 95205 | T 209 468-3420 | F 209 464-0138 | wwv/.s|qov.orq/ehd <br />The commissary is located in County. The above food facility meets the <br />’•ommissary requirements in California Health & Safety Code. The above checked services are available at the <br />above commissary. Please notify EHD if the status of their operating permit changes. <br />OMMISSARY AGREEMENT <br />■ Food Facility ♦ Caterer <br />SAN JOAQUIN <br />i k > v, n r y <br />Wastewater disposal <br />Solid waste disposal <br />ST 5 lot & Cold water for cleaning <br />Store dry food/supplies <br />I <br />"orrect to the <br />operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br />’rrnmissarv owner snail notify the EHD immediately. <br />; mature <br />o. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />To completed_by APPLICANT <br />w^.ness name C O W P J'Kf'S <br />^er/Ooerator Name [ril-follq <br />iusuiess Mailina Address <9/3S'" /V EL S4__________________________ <br />^•$hckc3 State</4 ZiD<?6-7/^ Bus. Ph. <br />I. herebv state that the above information is current, true and correct to <br />the best of my knowledge and agree to utilize my aooroved commissary in accordance with California Heaiin <br />Safety Code, and San Joaquin County Environmental Health Department (EHD) reauirements. If the use or me <br />commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in pern.» <br />revocation an^Wn^ib/ . . . - n <br />Signature (jf <br />Electrical hook-ups <br />Ip" Toilet and handwashing <br />C9"Potable water <br />Sir Vehicle wash <br />_ p \J . nereby state that the information I have provided is current, true and <br />"orrect to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility <br />Commissary Name California Catering Food Service & Supply FA# <br />Address 2440 S. Airport Way Bus. Phone <br />3iiv Stockton Zip 95206 Owner/Qperator Reyes Rubio <br />“i r.:: aii appropriate services provided: <br />3-compartnient sink <br />HjT Food preparation <br />C3 Store refrigerated food <br />Overnight parking <br />■ . A' ■ J <br />Lie. Plate n