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SWOON N Environmental Health Department <br /> ----COUNT'Y-- <br /> �, Gxtutirasa r4xx here. SALVADOR BLIENROSTRO <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 com' teted b APPLICANT <br /> Business Name JILL`S FRUIT ON TOP Lic. Plate# 4UH6903 <br /> Owner/Operator Name JUAN MACIAS <br /> Business Mailing Address 1944 REMEMBRANCE LANE <br /> City TRACY State CAZip 95377 Bus. Ph. 2092736609 Alt. Ph. <br /> 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 /> Signature '/ /��J <br /> �� Date 8/9/20222 <br /> 2. To be completed by COMMISSAEWY OWNE,RlOPERATOR <br /> Commissary Name. CALIFORNIA CATERING TRUCK WASH FA# <br /> Address 730 S. CALIFORNIA ST Bus. Phone 2092711741 <br /> City STOCKTON Zip 95203 Owner/Operator Salvador Buenrostro & Carmen <br /> Check all appropriate services provided: <br /> E3/WastewaterdisposaI @(3-compartment sink EYElectricalhook-ups <br /> E-Y'Solid waste disposal r(Food preparation d-toilet and handwashing <br /> Er Hot& Cold water for cleaning Ef Store refrigerated food Er Potable water <br /> 1211/store dry food/supplies Overnight parking E!r/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 /> commissawner hall notify the EHD i ediately. <br /> Signature A _� nll W !� QQ�A_ Date 8/9/2022 <br /> I To be cam ted-by the ENV HEALTH 'urtsdiction outside of San J; in. 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sigov.org/ehd <br />