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SAN JOAQUIN Environmental Health Department <br /> C1�:)UN, iY <br /> SALVADOR BUENROSTRO <br /> DBA CALIFORNIA CATERING TRUCK WASH <br /> 730 S CALIFORNIA ST <br /> COMMISSARY AGREEMENT ST©CKTON,CA95203 <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 La Guadalajara Lic. Plate# 50070K3 <br /> Owner/Operator Name Maryam Kore Ramirez Meza <br /> Business Mailing Address 2894 Raymond Ave <br /> City Stockton State CA Zip 95203 Bus. Ph. 818-390-8668 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 AHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature Date 11/1/23 <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 /> Wastewater disposal 12 3-compartment sink GY Electrical hook-ups <br /> f Solid waste disposal C$ Food preparation 12 Toilet and handwashing <br /> 0 Hot& Cold water for cleaning Q' Store refrigerated food 19 Potable water <br /> Store dry food/supplies Cfi Overnight parking (3 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 t comply with the conditions of is agreement, or if this agreement is modified or cancelled, the <br /> commissary o ner sha fytpeEHDimmeci ely. <br /> Signature r Date 11/1/23 <br /> uk <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 & 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 />