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JANJUAQUIN Environmental Health Department <br /> d„T <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 11 11: <br /> Business Name LULU &BETOS Lic. Plate# 6C24664 <br /> Owner/Operator Name Jenniffer C Guadalupe Sanvicente <br /> Business Mailing Address 6723 Plymouth RD 21 <br /> City STOCKTON State CAZip 95207 Bus, Ph. 2096433534 Alt. Ph. <br /> 1, , 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 an penalties. <br /> Signature Date 2/03/22 <br /> 2. To e completed by COMMISSARY OWNERIOPERATOR <br /> Commissary Name California Catering Tuck Wash FA# <br /> Address730 S California St Bus, Phone <br /> City Stockton Zip 95203 Owner/Operator. Salvador Buenrostro <br /> Check all appropriate services provided: <br /> 2'Wastewater disposal E20053-compartment sink Gr Electrical hook-ups <br /> I/Sow'waste disposal C]"Food preparation M"Toiiet and handwashing <br /> Hot&'told water for cleaning ErStore refrigerated food ZrPotable water <br /> Store dry food/supplies i(Overnight parking G 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 /> commissaryo ner shall notify the EHD immediate <br /> Signature - Date 2/03/22 <br /> 13. To be completed by the ENV HEALTH jurisdiction outside of Saft 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 1 Stockton. California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />