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SAN 10AQUIN Environmental Health Department <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 Tacos Los Dos Reales Lic. Plate# 31-122740 <br /> Owner/Operator Name Maria Del Rosario Medina <br /> Business Mailing Address 2515 Crestmore Cir <br /> City Stockton State CA Zip 95206 Bus. Ph. 209 922 5929 Alt. Ph. <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 permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Ar e w a /l e 3g'I �' Gin, 6 Date 1/14/2022 <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 /> Ef Wastewater disposal C?"3-compartment sink Rf Electrical hook-ups <br /> dSolid waste disposal i;KFood preparation C3/Toilet and handwashing <br /> 131Hot& Colcj'water for cleaning rstore refrigerated food Potable water <br /> a, Store dry food/supplies 12/Overnight parking Vehicle wash <br /> I, , hereby state that the information I have provided is current,true and <br /> correctto the best of my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails t comply with the conditions o his agreement, or if this agreement is modified or cancelled, the <br /> commissary w er shall 1 tify.the EHD imme is e1, <br /> Signature Date 1/14/2022 <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.orgiehd <br />