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SAN 10AOUlN Environmental Health Department <br /> --COUNTY--- <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 Mariscos EI Guero De Mazatlan Lic.Plate# 48029E3 <br /> Owner/Operator Name Gibran Rivera Torres <br /> Business Mailing Address 5052 E. Marsh St <br /> City STOCKTON State CAZip 95215 Bus. Ph. 209 -+575747 -,bAlt. Ph. <br /> I, ��I �_ 1 I in h.&% hereby state that the above information is current,true and correct to <br /> the best of my knowledig 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. A <br /> Signature G 4 Lay. !.4vQya Date 3/2/22 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Califonia 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 /> CKWastewater disposal U1 compartment sink �Vbectrical hook-ups <br /> to Solid waste disposal Food preparation EYToilet oilet and handwashing <br /> Q"Hot& C41d water for cleaning CrStore refrigerated food Votable water <br /> C3"store dry food/supplies 9/6-Vernight parking E�ehicle 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 /> commissary <br /> ^n ner shall notify the EHD immed�Ji�y. <br /> Signature h\ �I (1 rt,/ Inn✓1 'll U n n Date 3/2/22 <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.orgiehd <br />