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SAN ._J OAQ U I N Environmental Health Department <br /> C0UNJIY __.__ f" <br /> � SALVADQp RIFN)RINSTRO :� <br /> WCALIFORNIn r;kJCKWASH730 S ' <br /> COMMISSARY AGREEMENT STOCK"fTOCKTJNiti,iR+a�H sT <br /> OH X5203 <br /> Mobile Food Facility * Caterer il <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 Californi-Ana's Lic. Plate# 4RS5610 <br /> Owner/Operator Name Anabel Morales Barrera <br /> Business Mailing Address 3228 Deerfield ct <br /> City Stockton State CA Zip 95209 Bus. Ph. 209-702-4102 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 pen (ties. <br /> Signature Date 6/5/23 <br /> —01 <br /> 2. To be completed by COMMISSARY OWNEWOPERATOR <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 /> Q Wastewater disposal Q' 3-compartment sink Q' Electrical hook-ups <br /> E Solid waste disposal Q' Food preparation Q' Toilet and handwashing <br /> E Hot & Cold water for cleaning 17 Store refrigerated food U Potable water <br /> E Store dry food/supplies U Overnight parking 17 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 ner all notify the EH mmediately. <br /> Signature Date 6/5/23 <br /> 3. To be completed b� 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 /> 1 868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />