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SAN 10AQUIN Environmental Health Department <br /> SALVADOR BUENROSTRO <br /> DBA CALIFORNIA CATERING TRUCK WAST{ <br /> COMMISSARY AGREEMENT STOCKTON�AN95 0ST <br /> 3 <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 Magda Lic. Plate# 4UL7998 <br /> Owner/Operator Name Magda Elizabeth Sandoval <br /> Business Mailing Address 1718 E 13th St <br /> City Stockton State CAZip 95206 Bus. Ph. 209 610 4215 Alt. Ph. 408 472 0485 <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. 1 <br /> Signature �~VC,1 1 J V 1 L, r 1- Date 7/7/22 <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 209 464 970 <br /> City Stockton Zip 95203 Owner/Operator Salvador Buenrostro <br /> Check all appropriate services provided: <br /> dIWastewater disposal /3-compartment sink G3"Electrical hook-ups <br /> W/solid waste disposal M Food preparation ❑JToilet and handwashing <br /> [7f Hot & Cold water for cleaning I�Store refrigerated food ;Q Potable water <br /> ;Ystore dry food/supplies Cd/Overnight parking CKVehicle 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 /> commissa y Iwner s II notify the EHD im diately. <br /> Signature 'k, _ Date 7/7/22 <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. Hazeltcn Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www,sjgcv.org/ehd <br />