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� , ��10QQ +� Environmental Health Department <br /> —COUNTY-- <br /> i ' Greatness cr^�.r i <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 9 Caterer <br /> Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> kA� ° tedl 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 CA Zip 95206 Bus. Ph. 707 890 2399 Alt. Ph. <br /> I, Man'dLj Q Gc.2n�a�, , 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 Ne'r at,6 C,t/2..,ar Date 10/26/2021 <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 <br /> City Stockton Zip 95203 Owner/Operator Salvador Buenrostro <br /> Check all appropriate services provided: <br /> )wastewater disposal 12111-compartment sink L"Electrical hook-ups <br /> C!r'Solid waste disposal iB-Food preparation ZfToilet and handwashing <br /> ErHot& Cold water for cleaning O-Store refrigerated food 11�Potable water <br /> If Store dry food/supplies arovernight parking [] Vehicle wash <br /> 1, , 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 er shallti the EHD immediat <br /> Signa �Alhrylln I/Lfi✓ Date 10/26/2021 <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 />