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szo��s� <br /> SAN 10AQUIN Environmental Health Department <br /> SALVADOR BUENROSTRO <br /> DBA CALIFORNIA CATERING TRUCK WASH <br /> COMMISSARY AGREEs OCKrON CA9 203 <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 Tacos La Yolanda Lic. Plate# 5h78255 <br /> Owner/Operator Name Cesar Alberto Paez-Villasenor <br /> Business Mailing Address 1555 S Adelbert Ave <br /> City Stockton State CAZip 95215 Bus. Ph. 209 326 7123 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 /> / <br /> Signature��ci Y �,��'� Date 7/19/22 <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 209 271 1741 <br /> City Stockton Zip 95203 Owner/Operator Salvador Buenrostro <br /> Check all appropriate services provided: <br /> pj Wastewater disposal [3'3-compartment sink OlElectrical hook-ups <br /> Solid waste disposal 0 Food preparation O"'Toilet and handwashing <br /> Hot & Cold water for cleaning Q( Store refrigerated food P, Potable water <br /> 111"Store dry food/supplies 0 Overnight parking Ell`�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 /> commissary w er shall otify the EHD immedi t ly. <br /> Signature��� Date 7/19/22 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />