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.�PCWiN-com <br /> ` SAN JOA UIN Environmental Health Department <br /> -COUNTY-Greatness grows here. SALVADORBUENROSTRO <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. ff your commissary is located outside of San Joaquin County also complete section 3. <br /> 1. To be completed by APPLICANT <br /> Business Name Lic.Plate# 6A L5 zq <br /> Owner/Operator Name e <br /> Business Mailing Address <br /> City <br /> =s <br /> State 4L (20 s. P <br /> I,� pmt f ��,hereby state that the above information is current,true and correct to <br /> the best ofmy 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 /> revocatio an q n <br /> SignatuDate �i- <br /> 2 e completed by COM IS ARY OWNER/OPERATOR <br /> Commissary Nam \ �'�# n <br /> Address Bus. Plione C <br /> City _Zip OwnerJOperator `V <br /> Check all appropriate services provided: <br /> p'A�lastewaterdisposal compartment sink 151'1�1_ectrical hook-ups <br /> rk-S-olid waste disposal I21'*F�ood preparation 0V1oilet and handwashing <br /> _-O�Hot Coldwater for cleaning CP Ttore refrigerated food 2-Potable water <br /> Store dry food/supplies Call5vernight parking Er a-hicle wash <br /> I, /� , hereby state that the information I have provided is current,true and <br /> correct tot a 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 /> commissaryownr shall notify a EHD immediately. <br /> Signature Date a V <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.sjgov.org/ehd <br />