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SAN JOAQUIN 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 Charlie's Fruti Loco Lic. Plate# 4PB4647 <br />Owner/Operator Name Juan Carlos Macias <br />Business Mailing Address 804 Fallen Leaf <br />City Modesto State CA Zip95351 Bus. Ph. 209 579 4787 Alt. Ph <br />I, hereby state that the above information is current, true and correct to <br />th est of my kno e%dge d 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 />12. T6be comDleted by COMMISSARY OWNER/OPERATOR I <br />Commissary Name California Catering Truck Wash FA# <br />Address 730 S. California St Bus. Phone 209 464 9707 <br />City Stockton Zip 9503 Owner/Operator Salvador Buenrostro <br />Check all appropriate services provided: <br />GKWastewater disposal compartment sink $ Electrical hook-ups <br />petolid waste disposal Q"Food preparation -PrToilet and handwashing <br />I <br />D'Hot & Od water for cleaning �Store refrigerated food P_ PPotable water <br />la Store dry food/ plies H Overnight parking to 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 />commissarygwler shallArotify the EHD immadrtely. <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 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />