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s � <br /> S Q N J O Q Q U I N Environmental Health Department <br /> SALVADOR t3UENROS rHG <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. It your commissary is located outside of San Joaquin County also complete section 3. <br /> a 1. To be completed by APPLICANT <br /> r <br /> Business Name DON RAFAS TACO SHOP Lic.Plate# 46148R2 <br /> Owner/Operator Name RAFAEL CASTILLO ESTRADA <br /> Business Mailing Address 1248 E. MINER AVE <br /> City STOCKTON State CA Zip 95205 Bus. Ph. 2098298539 Alt. Ph. <br /> I, ,hereby stale 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 discornti��,the permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and pen I ' <br /> Signature Date 8/10/2023 <br /> 12. 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 /> W Wastewater disposal 12 3-compartment sink U Electrical hook-ups <br /> t?' Solid waste disposal [2 Food preparation 9 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning 9 Store refrigerated food 13 Potable water <br /> G Store dry food/supplies Q' Overnight parking Q' 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 /> commissa owner shall otify the EHD im diately. <br /> Signature / Date 8/10/2023 <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 & Safely Code. The above checked services are available at the 7 <br /> i <br /> above commissary. Please notify EHD if the status of their operating permit changes. <br /> REHS Signature _Date <br /> t 81358 E.Hazelton Avenue I Stockton,California 952051 T 209468-34201 F 209464-0138 lwww.sjgov.org/ehd <br />