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SAN OAQUIN Environmental Health Department <br /> ��. r;;' COUNTY <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 NameCharly's Super Tortas Chilangas Lic. Plate# 8VYK098 <br /> Owner/Operator Name Brenda Lopez <br /> Business Mailing Address 2725 E Fremont St <br /> City Stockton State CA Zip 95205 Bus. Ph. (209) 646-1450 Alt. Ph. (916) 346-9828 <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 disconti ued, the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penal s. <br /> Signature Date 10/19/2021 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name California Catering Truck Wash FA# (209) 464-9707 <br /> Address 730 S. California St Bus. Phone (209) 464 -9707 <br /> City Stockton Zip 95203 Owner/Operator Salvador Buenrostro <br /> Check all appropriate services provided: <br /> "astewater disposal �J-compartment sink Electrical hook-ups <br /> olid waste disposal E Food preparation 13�Toilet and handwashing <br /> C�lHot& Cold water for cleaning ESto refrigerated food .Potable water <br /> alstore dry food/supplies Overnight parking C3 Vehicle wash <br /> I, Salvador Buenrostro , 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 a reement, or if this agreement is modified or cancelled, the <br /> commissary ow��ne(I shall notify ft EHD immediately. <br /> Signeture_Y1/1 �� VUSL Date 10/19/2021 <br /> 3. To 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 /> 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 />