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SANJOAQUIN Environmental'Realth Department <br /> COU RI T Y----- SALVADOR RUFNROSTRO <br /> DBACAUFOHN!It,�,P ?~.HNGTRUCKWASH <br /> l7rt=rk'77?SS u''Ut•., 'rst. ,. <br /> 7311 S"I"AuFORNIA ST <br /> STOCKTUN,CA 95203 h <br /> COMMISSARY AGREEMENT-__-_, <br /> Mobile Food Facility o, 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 Mikey's Lic. Plate# 4SG4557 <br /> Owner/Operator Name Miguel Ventura <br /> Business Mailing Address 1844:S Calfornia St <br /> City Stockton State CA Zip 95206 Bus. Ph. 209 518:7014 Alt. Ph. <br /> 1, hereby state that the above information is current,true and correct to <br /> the be6t 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 pen (ties. <br /> SignatureL)jk Date 7/13/22 <br /> 2. To be com leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name California Catering Truck Wash FA# <br /> Address 730 S California ST Bus. Phone <br /> City Stockton Zip 95203 Owner/Operator Salvador Buenrostro <br /> Check all appropriate services provided: <br /> Wastewater disposal CY3-compartment sink CElectrical hook-ups <br /> Solid waste disposal ["Food preparation ®'Toilet and handwashing <br /> ErHot & Cold water for cleaning 0'Store refrigerated food `Potable water <br /> Store dry food/supplies ® Overnight parking ® 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 /> commissaowner shall notify the EHD immediately. <br /> Signature Date 7/13/22 <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.sjgov.org/ehd <br />