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SAN 10AQUIN Environmental Health Department <br /> SALVADOR t3UENROSTRO <br /> DBA CALIFORNIA CATERING TRUCK WASH <br /> 730 S CALFORNIA ST <br /> COMMISSARY AGREEMENT STOCKTON,CA 952M <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 completed by APPLICANT <br /> Business Name DON RAFAS TACO SHOP Lic.Plate# 90809G2 <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, RAFAEL CASTILLO ,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 Joaqui unty Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discontinued,t p holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penaltie . <br /> Signature Date 8/10/2023 <br /> 2. To be com le 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 /> p Wastewater disposal Q' 3-compartment sink Q' Electrical hook-ups <br /> B Solid waste disposal 9 Food preparation 12 Toilet and handwashing <br /> H Hot& Cold water for cleaning G Store refrigerated food 17 Potable water <br /> H Store dry food/supplies Q' Overnight parking 9 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 ow r shall notify the EHD im diately. <br /> Signature /1 Date 8/10/2023 <br /> IVVV-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.slgo�.org eh.+ <br />