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SANJOAQUIN Department <br /> Environmental Health De <br /> —COUNTY-- <br /> ;,;tt� .�' �iJeptmsq grows t+ ar. SALVADORBUENROSTRO <br /> DBA CALIFORNIA CATERING TRUCK WASH <br /> 730 S CALIFORA ST <br /> COMMISSARY AGREEMENT STOCKTON CA 95 03 <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 /> Business Name CHARLY"S SUPER TORTAS CHILANGAS Lic. Plate# 356755G3 <br /> Owner/Operator Name BRENDA LOPEZ SERRANO <br /> Business Mailing Address 350 HORTON AVE <br /> City STOCKTON StateCA Zip 95206 Bus. Ph. 916/3466668 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 ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date 12/16/22 <br /> 2. To com ..leted by COMMISSARY OWNER/OPERATOR <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 /> 12 Wastewater disposal 67' 3-compartment sink 12 Electrical hook-ups <br /> U Solid waste disposal t7' Food preparation 12 Toilet and handwashing <br /> ® Hot & Cold water for cleaning U Store refrigerated food 1' Potable water <br /> ® Store dry food/supplies Et Overnight parking G 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 o nerInvyw/M <br /> I notify the EHD ediately. <br /> Signature r" 6 1 <br /> 44,1JI, Date 12/16/22 <br /> IV �Ivk <br /> 3: To'be'com° k the`ENV HEALT t Sdiction outside of San Joa wn" o <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 d <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 />