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SAN J OAQ U I N Environmental Health Department <br /> C0U KATY <br /> SALVADOR BUENROSTRO <br /> DBA CALIFORNIA CATERING TRUCK WASH <br /> COMMISSARY AGREEMENT STOCKTON ca 203 <br /> Mobile Food Facility e 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 Elotes EI Muneco Lic. Plate# 4VF5934 <br /> Owner/Operator Name Rodolfo Vidaca <br /> Business Mailing Address 2035 S Pilgrim St. <br /> City Stockton State CA Zip 95206 Bus. Ph. 209-662-9113 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 5/22/23 <br /> 2. To be 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 /> Q Wastewater disposal Ck 3-compartment sink U Electrical hook-ups <br /> Ea Solid waste disposal Ck Food preparation Ck Toilet and handwashing <br /> 0 Hot & Cold water for cleaning 17 Store refrigerated food 17 Potable water <br /> Fd Store dry food/supplies U Overnight parking (7 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 /> commissar, caner s all notify the EHD i ediately. <br /> Signature Date 5/22/23 <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joa in 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 />