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SAN ) 0 AO U I N Environmental Health Department <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility , Caterer <br /> Complete sections i 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 Durango's Cafe Lic. Plate#4AL1811 ATZ8093 <br /> Owner/Operator Name Ibarra Fernanda <br /> Business Mailing Address 1660 Beyer Ln <br /> City Stockton StateCA Zip 95215 Bus. Ph. 209 323 0885 Alt. Ph.209 628 9557 <br /> I, , 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 ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a penalties. <br /> Signature 0Ajyr2jA264 Date 1/20/22 <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 /> wastewater disposal 0-�3-compartment sink dElectrical hook-ups <br /> olid waste disposal O'F od preparation [y'Toilet and handwashing <br /> rHot & Cold water for cleaning ore refrigerated food �/Potable water <br /> 12 Store dry food/supplies ,"J/StOvernight parking l71 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 a Bement, or if this agreement is modified or cancelled, the <br /> commissary o ner shall o ify the EHD immediatel <br /> Signature Date 1/20/22 <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 />