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SANdHOUIN Environmental Health Department <br /> COUNTY— <br /> ._.. <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 EI Guadalajara Lic. Plate# 6V94696 <br /> Owner/Operator Name JOSE LUCIANO ORDINOLA HERNANDEZ <br /> Business Mailing Address 1612 s sacramento st <br /> City Lodi State C�rAZip 95240 Bus. Ph. 916 541-7734 Alt. Ph. <br /> 1,JOSC L%-'CA uno d, F( , 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�105'C [Lu uno Q, ty Date 10/20/2021 <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 CA Owner/Operator Salvador Buenrostro <br /> Check all appropriate services provided: <br /> .1W tewater disposal 0'3-compartment sink J2-Electrical hook-ups <br /> 13 Sc waste disposal Er Food preparation 13-Toilet and handwashing <br /> Q Hot& Cold water for cleaning CrStore refrigerated food I:J'—Potable water <br /> n <br /> i3-Sfore dry food/supplies g-OvgFnight parking 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 agreement, or if this agreement is modified or cancelled, the <br /> commissary o n r�shall notAfy the EHD immediately/) <br /> Signature V ' Ill Vv LL(q�//���� Date 10/20/2021 <br /> 3. To be completed b 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 />