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SANAMUIN Environmental Health Department <br /> — <br /> -COUNTY-- - <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility s 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 TAQUERIA LOS BORRACHOS Lic. Plate# 7E74498 <br /> Owner/Operator Name JORGE L. MORENO <br /> Business Mailing Address 3112 BELVEDERE AVE APT#14 <br /> City STOCKTON State(CA Zip 95205 Bus. Ph. 2095097471 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 EnviroDmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,the W it h r must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature — Date 3/10/22 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name California Catering Truck 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 /> p,'Wastewater disposal 13/3-compartment sink la E�lectrical hook-ups <br /> If"Bolid waste disposal �ood preparation Q'Toilet and handwashing <br /> VqJHot& Cold water for cleaning �70vernight <br /> e refrigerated food ['Potable water <br /> EI Store dry food/supplies parking dVehicle 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 /> commissa nener sha7{i�notify the EHD immedi ly. SALVADOR BLIENROSTRO <br /> Signature <br /> 11\ \ MV S/� k�Date 3/10/220BA CALIFORNIA CATERING TRUCK WASH <br /> IA ST <br /> STOC <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San JOa u' o. 203 <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 />