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SAN-JOAQUIN Environmental Health Department <br /> --COUNTY--- <br /> G,Pot n,,K, ,,,F,., <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility e 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 Tee Jays Infoodsion Lic. Plate# 61-111640 <br /> Owner/Operator Name Beatriz Cedeno <br /> Business Mailing Address 4029 N. Cherryland Ave <br /> City Stockton State CA Zip 95215 Bus. Ph. 209 910 7396 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 ` _ Date 11/16/2021 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name California Catering Truck Wash FA#—2094649707 <br /> Address 730 S California St Bus. Phone 209 464 9707 <br /> City Stockton Zip 95203 Owner/Operator Salvadoir Buenrostro <br /> Chec all appropriate services provided: <br /> [Wastewater disposal PJ 3- ompartment sink Electrical hook-ups <br /> Q/Solid waste disposal fzJ Food preparation Toilet and handwashing <br /> J7 <br /> Hot & Cold water for cleaning (3IStore refrigerated food 6 P table water <br /> 0 Store dry food/supplies ; Overnight parking 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 agreement, or if this agreement is modified or cancelled, the <br /> commissarylo"�'ershallUiK <br /> fythe EHD immediinly. <br /> Signature p 11 0 Q4J I {t�1,4/4q� Date 11/16/2021 <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 />