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Jl <br /> SAN z,JOAOUIN Environmental Health Department <br /> NTv---- <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 Birrieria y Taqueria Los Matados Lic. Plate# 7T66951 <br /> Owner/Operator Name Jesus A. Hernandez <br /> Business Mailing Address 2705 W Alpine Avenue <br /> City STOCKTON State CAZip 95204 Bus. Ph. 2096880033 Alt. Ph. <br /> I, Jesus A Hernandez , 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. n ' <br /> Signature Z:S[us A ,g9Kn aride� Date 2107/22 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> CommissaryName California Catering Tuck Wash FA# <br /> Address 730 S California St Bus. Phone 2092711741 <br /> City Stockton Zip 95203 Owner/Operator Salvador Buenrostro <br /> Check all appropriate services provided: <br /> )(Wastewater disposal [7K3-compartment sink C3/Electrical hook-ups <br /> (,Solid wastg disposal —/Food preparation G3 Toilet and handwashing <br /> C(Hot& Cola water for cleaning La Store refrigerated food 13 Potable water <br /> 12Store dry food/supplies Overnight 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�he food facility <br /> operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa o�wn,.e��r/�Jtall noti the EHD immediat . <br /> Signature�/I c �II( ri At M (U4 \ Date 2/03/22 <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 />