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SAN J GAO U IN Environmental Health Department <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 Birria y Tacos Guzman Lic. Plate# 4NF1395 <br /> Owner/Operator Name Mariano Guzman <br /> Business Mailing Address 2363 Starboard Ln <br /> city Stockton State CAZlp 95206 Bus. Ph. 707 890 2399 Alt. Ph- <br /> 1. t"�an a r,v (�2m a v, , 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 N/a tiay.cs cr Date 10/26/2021 <br /> 2. To be com feted b COMMISSARY OWNERIOPERATOR <br /> Commissary Name California Catering Truck wash FA# 209 464 9707 <br /> Address 730 S California St Bus. Phone <br /> City Stockton Zip 95203 Owner/Operator Salvador Buenrostro <br /> Check all appropriate services provided: <br /> wastewater disposal 0-53-compartment sink E3rbectrical hook-ups <br /> Solid waste disposal Food preparation Toilet and handwashing <br /> 9-Hot& Cold water for cleaning lam-Store refrigerated food ;;� Potable water <br /> Store dry food/supplies overnight parking L 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 /> commissao ershall ti the EHD immediat <br /> Date 10/26/2021 <br /> Signaturery <br /> 3. To be com feted b the ENV HEALTH 'urisdiction outside of San Joa uin Co. <br /> The commissary is located in County. The above food facility meets the <br /> s 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 /> 180$ E. zazelton Avenue Stockfon, California 95205 T 209 A63-34201 F 209 364-0138 i v-A'1v,r.sjgov.orglehd <br /> E <br />