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� SAUGAOUIN <br />— COUNTV— <br />J Environmental Health Department <br />re,,,f►1 G SALVADOR BUENROSTRO <br />rno leers QrO..% here. <br />DBA CALI 79CK WAS <br />0 S CALFORNIA ST <br />COMMISSARY AGREEMENT STOCKTON, CA 95203 <br />Mobile Food Facility s Caterer <br />Complete sections 7 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />1,.pted by. APPLICANT <br />Business Name Antoiitos Nica v Mas _Lic. Plate # 4RW5996 <br />Owner/Operator Name Jorge Alberto Cuadra Pinell <br />Business Mailing Address 7818 Finnh rse Wa <br />City Sacramento State CA Zip 95828 Bus. Ph. 650 491 4642 Alt. Ph. <br />l,T .,,-.,, A 1h cr-L C l,_,IKI hereby state that the above information Is current, true and correct to <br />the b>�y 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 />--I.---.:-- --J ---- W -- <br />Commissary Name California Catering Truck Wash _FA# 209-464-9707 <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 />U Wastewater disposal GY 3 -compartment sink 12 Electrical hook-ups <br />H Solid waste disposal Gr Food preparation 12 Toilet and handwashing <br />S Hot & Cold water for cleaning Gr Store refrigerated food U Potable water <br />H Store dry food/supplies ET Overnight parking Q Vehicle wash <br />1, , 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 ovAner shall notify the EHD immediamy. <br />3. To be completed by the ENV HEALTH jurisdiction outside.of She: Joaquin Co: I <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 4640138 1 www.sigov.orgfehd <br />