Laserfiche WebLink
SAN _1 OA Q U I N Environmental Health Department <br /> COUNT, <br /> v 't"° SALVADOR BUENROSTRO <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 <br /> completed by APPLICANT <br /> Business Name MMM FUSION INC BDA-FUSION BOBA CAFE Lic. Plate# R6M1CG24NB000258 <br /> Owner/Operator Name GRACE MEI & ANTHONY LIMA <br /> Business Mailing Address 25 S. HUNTER ST <br /> City STOCKTON State CA Zip95202 Bus. Ph.209-641-2392 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 permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date 3/25/23 <br /> 2. Tobe completed 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 CZ 3-compartment sink CY Electrical hook-ups <br /> E3 Solid waste disposal Ck Food preparation Cr Toilet and handwashing <br /> 0 Hot & Cold water for cleaning 12 Store refrigerated food 1' Potable water <br /> H Store fo li s U Overnight parking U Vehicle wash <br /> I, hereby state that the information I have provided is current,true and <br /> corre to the be t my knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary owner shall notify the EHD immediately. <br /> Signature Date 3/25/23 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa uin 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 />