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SAN ,JOAQUIN Environmental Health Department <br /> COUNTY— <br /> COMMISSARY <br /> OUNTY— <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 RASPADOS PANDITA Lic.Plate# 4TN7681 <br /> Owner/Operator Name GERMAN LOPEZ <br /> Business Mailing Address 763 FOLSOM WAY <br /> City MANT�ECA StateCA /Zip_ 95337 Bus. Ph.4085040369 Alt. Ph. <br /> 1. Q V VVL& 1 I Yl V TC Z hereby state that the above information is current,true and correct to <br /> the best of my knowledge and gr a 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 alties. r <br /> Signatur Date 3/3/22 <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 2094649707 <br /> City STOCKTON Zip 95203 Owner/Operator 2092711741 <br /> Check all appropriate services provided: <br /> . W'stewater disposal 134--compartment sink EI-Electrical hook-ups <br /> Solid waste disposal mood preparation EI'oilet and handwashing <br /> Ca Ho & Cold water for cleaning MSt re refrigerated food "Potable water <br /> St re dry food/supplie Overnight parking 13 Vehicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> come t 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 caner shjRII notify the EHD im ediately. <br /> Signature Date 3/3/22 <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.org/ehd <br />