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SAN J O A Q U I N Environmental Health Department <br /> U N TY <br /> SALVADOR BLIENROSTRO <br /> DBA CALIFORNIA CATERING TRUCK WASH <br /> 730 S CALFORNIA ST <br /> STOCKTON,CA 95203 <br /> COMMISSARY AGREEMENT <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 /> Green Bawarchi 9KVN614 <br /> Business Name Lic. Plate# <br /> Owner/Operator Name Kota Sai Kalyan <br /> Business Mailing Address 2676 Garden Farms Ave <br /> City Lathrop State CAZip 95330 Bus. Ph. 408-930-9009 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 EHD. Failure to notify this office may result in permit <br /> revocation and penalties. <br /> Signature `? Date 2/23/24 <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 U Electrical hook-ups <br /> Solid waste disposal 12 Food preparation 9 Toilet and handwashing <br /> Hot & Cold water for cleaning 17 Store refrigerated food Q' Potable water <br /> 0 Store dry food/supplies U Overnight parking U 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 /> commissary caner s II notify the EHD i ediately. <br /> Signature Date 2/23/24 <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 /> t 868 E. Hazelton Avenue I Stockton, California 95205. 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> RO2 DS 119 9 00 <br />