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SAN ]OAQUIN Environmental Health Department <br /> ---COUNTY <br /> • _40 <br /> SALVADOR BUENtif.;S7'RO <br /> 013A CALIFORNIA CA'!T,NN' ^,t,y�;r.,WASH <br /> COMMISSARY AGREEME 730 ..:A,J <br /> STOCKTON, �"',ti e6203 <br /> Mobile Food Facility 4- 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 Marias Lic. Plate# 84104P3 <br /> Owner/Operator Name Mario A Carrillo Maria Guadalupe Bustuaute <br /> Business Mailing Address 2245 Bartran Run Way <br /> City Stockton State CAZip 95112 Bus. Ph. 209-696-7484 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 END. Failure to notify this office may result in permit <br /> revocation and penalties. _ <br /> Signature -� ;we E{c 1� ,�� 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 /> 1' Wastewater disposal 12 3-compartment sink 12 Electrical hook-ups <br /> B Solid waste disposal 9 Food preparation [2 Toilet and handwashing <br /> H Hot & Cold water for cleaning G Store refrigerated food 17 Potable water <br /> 71 Store dry food/supplies G 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 c mply with th 'conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissary own shall notify e EHD immediately. <br /> Signature A Date 2/23/24 <br /> 3. To be completed Yy 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 /> PRI, 0Sg8q (.01 <br />