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SAN JOAQUIN Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility 4 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 Tacos EI Rapido Lic. Plate# 42176Y1 <br /> Owner/Operator Name Osvaldo Guerrero <br /> Business Mailing Address 4456 Demby Ln <br /> City Stockton St eCA Zip 95207 Bus. Ph. 209 224 6643 Alt. Ph. <br /> I,Lc,VGP0 6c4zl iffQ , 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 G�chD�Cezitrl) Date1/17/2022 <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 /> dastewater disposal Z� 3-compartment sink Electrical hook-ups <br /> [� olid waEtke disposal ZI Food preparation /Toilet and handwashing <br /> 1 t& Cokf water for cleaning /Store refrigerated food _M_ Potable water <br /> ❑ .Store dry food/supplies [� Overnight parking R"Vehicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> correct.So 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 /> commissaryoner shal notify the EHD imm lately. <br /> Signature �.I�OW/� Date 1/17/2022 <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 />