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SAN 10AQUIN Environmental Health Department <br /> —COU NTY— <br /> __ ,:reetn:,s; grow$ {ter_. <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 /� L Lic. Plate# L) <br /> NilaOwner/Operator Name e <br /> Busines `M 'lliiin(g,Addressj-±D3 �F <br /> Citys<i � I State Zip 952DS Bus. Ph E-�' D Alt. Ph. <br /> 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 MO-T'�-U �5c>r��CtieZ_ �4�cf41P�� Date i 22 <br /> 2. Tobe com lete. ..yz'',MI as <br /> Commissary Name California Catering Truck Wash FA# 209 464 9707 <br /> Address 730 S. California Bus. Phone 209 464 9707 <br /> c <br /> City Stockton Zip 95203 Owner/Operator Salvador Buenrostro <br /> C all appropriate services provided: <br /> Wastewater disposal 13(3-compartment sink H/ ectrical hook-ups <br /> Q solid waste disposal Food preparation oilet and handwashing <br /> f,3 &Cold water for cleaning tore refrigerated food � table water <br /> Store dry food/supplies Overnight parking 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 owner shall notify the EHD imme <br /> Aately. n <br /> Signature1\Il�r r 114 Date <br /> 3. To be corn' leted l .the ENV HEALTH 'u; sdictipnngktstd' <br /> TIt'e 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 /> d� <br />