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SANJOAQUIN Environmental Health Department <br /> i •---COU N T Y SALVADOR SUBNFROS'tRO <br /> DBA CALIFORNIA GAT15RING-`RUCK WA3hl <br /> Grp rnecs Gtows her 730 S CALFORNIA ST <br /> STOCKTON,CA 96203 <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 LAS LUPITAS Lic. Plate# 1 JG4284 <br /> Owner/Operator Name GUADALUPE CABRERA VERA <br /> Business Mailing Address 1227 COLLEGE AVE <br /> City STOCKTON StateCA Zip 95205 Bus. Ph. 2096635930 Alt. Ph. <br /> 1. , 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 renalties. <br /> Signature � lh )C?4�QA Date 12/6/2023 <br /> 2. To be completed by COMMISSAR%' 01/VNER/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 /> U Wastewater disposal 12 3-compartment sink 12 Electrical hook-ups <br /> E' Solid waste disposal 12 r=ood preparation W a' Toilet and handwashing <br /> E3 Hot & Cold water for cleaning G Store refrigerated food Q' Potable water <br /> Ed Store dry food/supplies Ea' Overnight parking 13 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 condition of thisy.,agreement, or if this agreement is modified or cancelled, the <br /> commissary lot <br /> ner sh notify the EHD im diatelI� <br /> Signature Date _ <br /> i <br /> 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. j <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 />