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SAN J O A Q U I N Environmental Health Department <br />SALVADOR BUENROSTRO <br />DBA CALIFORNIA CATERING TRUCK WASH <br />730 S CALFORNIA ST <br />COMMISSARY AGREEMENT STOCKTON, CA 95203 <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 Los Jose's Lic. Plate # 8B95158 <br />Owner/Operator Name Gabriel Agustin Alcazar <br />Business Mailing Address 2532 E 9th <br />City Stockton State CAZip 95205 Bus. Ph. 209 687 5352 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 />12. To be comDleted by COMMISSARY OWNER/OPERATOR <br />Commissary Name California Catering truck Wash FA#_ <br />Address730 S California St Bus. Phone 209 271 1741 <br />City Stockton Zip 95203 Owner/Operator Salvador Buenrostro <br />Check all appropriate services provided: <br />El/Wastewater disposal <br />EY'Solid waste disposal <br />t & Cold water for cleaning <br />Q Store dry food/supplies <br />Cr'*�3-compartment sink <br />Food preparation <br />Z,Store refrigerated food <br />Overnight parking <br />CrElectrical hook-ups <br />15 <br />Toilet and handwashing <br />EY -Potable water <br />2 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 oVner shall Aotify the EHD immeditely. <br />Signature <br />13. 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. <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 />