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SAK JOAQUIN Environmental Health Department <br /> COUNTY <br /> SALVADOR BUENROSTRO <br /> DBA CALIFORNIA CATERING TRUCK WASH <br /> 730 S COMMISSARY AGREEMENT STOCKTON CAN z03 <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 EI JR Kitchen Express Lic. Plate# V698645 <br /> Owner/Operator Name Alma Casas Medina, Rene Medina Marin <br /> Business Mailing Address 1915 W. Woodward Ave <br /> City Manteca State CA Zip 95337 Bus. Ph. 209 629 7452 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 an It's <br /> Signature Date 8/3/22 <br /> 2. To be completed by COMMISSARY OWNEWPERATOR <br /> Commissary Name California Catering Truck Wash FA# 209464-9707 <br /> Address 730 S California St Bus. Phone 209-271-1741 <br /> City Stockton Zip 95203 Owner/Operator Salvador Buenrostro & Carmen Rivera <br /> Check all appropriate services provided: <br /> Ij Wastewater disposal 12 3-compartment sink 12 Electrical hook-ups <br /> H Solid waste disposal 12 Food preparation 17 Toilet and handwashing <br /> H Hot& Cold water for cleaning EY Store refrigerated food 17 Potable water <br /> H Store dry food/supplies 177 Overnight parking 13 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 /> commissa caner sha notify the EHD immedia ly. <br /> SignatureDate 8/3/22 <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.sigov.org/ehd <br />