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SAN )O A Q U I N Environmental Health Department <br /> SALVADOR DUENROSTRO <br /> DUA CALIFORNIA CATERING TRUCK WASE+ <br /> 730 S CALIFORNIA 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 completed by APPLICANT <br /> Business Name DON RAFAS TACO SHOP Lic.Plate# 53292F2 <br /> Ov ner/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 S i oaqu'i'n/County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary is discon ue rte permit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation and penalti <br /> Signature Date 8/10/2023 <br /> 2. To be comp e ed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name California Catering Truck Wash FA# 209-464-9707 <br /> g 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 12 Electrical hook-ups <br /> G✓ Solid waste disposal 12 Food preparation 12 Toilet and handwashing <br /> G Hot & Cold water for cleaning Ca' Store refrigerated food 19 Potable water <br /> • Store dry food/supplies 1Z Overnight parking 19 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 /> commissaryo ner shall�ptify the EHD imm� iately. <br /> Signature Date 8/10/2023 <br /> F3. 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 952051 1 209 468-34201 F 209 464-0138 1 www.sjgov.org/ehd <br />