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SAN JOAQUIN Envir'onrnei'antal Health Department <br /> C <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> 1, To be completed by APPLICANT <br /> Business Name Las Delicias del Barrio #2 Lic. Plate# 8K54243 <br /> Owner/Operator Name Miguel Valenzuela <br /> Business Mailing Address 564 W sneed rd <br /> City french camp State CA Zip 95231 Bus.--Ph. 209 326 6685 Alt. Ph. <br /> I, hereby state that the above information is current,true and correct to <br /> the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature i\ Date 12/6/2021 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name California Catering Truck Wash FA# 209 464 9707 <br /> Address 730 S Califomia St Bus. Phone 209 464 9707 <br /> City Stockton Zip 95203 Owner/Operator Salvador Buenrostro <br /> Check all appropriate services prKNd : <br /> ,/Wastewater disposal Ck-compartment sink Electrical hook-ups <br /> �SSolid waste disposal Pr Food preparation o-loilet and handwashing <br /> i_Yot& Cold water for cleaning C'1 Store refrigerated food jam'Potable water <br /> Ar/HStore dry food/supplies O Overnight parking Q Vehicle wash <br /> I, , hereby state that the information I have provided is current, true and <br /> correct to the best of my knowledge,and meets the California Health &Safety Code requirements. If the food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary ow er shall tify the EHD imm ately. <br /> Signature r l%i,J(�Lj - _ _Date 12/6/2021 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin Co. <br /> The commissary is located in County. The above food facility meets the <br /> commissary 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 /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />