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SAN JOAQUIN Environmental Health Department <br />CC)UP. TY <br />SALVADOR BUENROSTRO <br />DBA CALIFORNIA CATERING TRUCK WASH <br />730 S CALFORNIA 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 I <br />Business Name TAQUERIA EL CARNAVALITO Lic. Plate # 4UT8642 <br />Owner/Operator Name MIGUEL RODRIGUEZ ANDRADE <br />Business Mailing Address 4114 N PERSHING AVE <br />City STOCKTON StateCA Zip 95207 Bus. Ph.2095616603 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 Denalties. <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 />13 Wastewater disposal 12 3 -compartment sink 12 Electrical hook-ups <br />6 Solid waste disposal 12 Food preparation Q' Toilet and handwashing <br />® Hot & Cold water for cleaning 17 Store refrigerated food Q' Potable water <br />® Store dry food/supplies 12 Overnight parking [7 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 />3. To be completed by the ENV HEALTH jurisdiction outside of San Joa in 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 <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 />