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Commissary Namelij <br />Address -10j) <br />City <br />SAN JOAQUIN <br />--COUNTY --- <br />Environmental Health Department <br />aera:e <br />Orr Grcorness grows here, SALVADOR BUENROSTRO <br />Df3A CALIFORNIA CATERING TRUCK WASH <br />730 S CALFORNIA ST <br />COMMISSARY AGREEMENT STOCKTON, CA 95203 <br />Mobile Food Facility 4 Caterer <br />1. To be completed by APPLICANT <br />// Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br />Business Name For, CI_ 41"v' <br />Owner/Operator Name k t) uu oniq <br />Business Mailing Address 10Z' rie d‘s 162- <br />Lic. Plate # (/ 0 '70 (1.2 <br />laccw,"-^ State CIA. Zip (-15' Bus. Ph. 33 --/0,4•0 Alt. Ph. <br />I, 14,4JeNuo cA , 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 discontin pd, the permit holder must notify the END. Failure to notify this office may result in permit <br />revocation and penalti <br />Signature <br /> <br /> Date 16 — / / <br /> <br />2. To be completed b COMMISSARY OWNER/OPERATOR <br />611-e tvitty_wA <br />Zip <br />fIc Bus. Ph <br />b Owner/Operator <br />Check all appropriate services provided: <br />r--EyWastewater disposal 131-compartment sink <br />CKSolid waste disposal irFood preparation <br />& Cold water for cleaning 1::Store refrigerated food <br />r.:K;re d food/supplies 1:'6vernight parking <br /> , hereby state that the information I have provided is current, true and <br />co rect to the est of my kn e ge, 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 />kAji,/(_ Date 1)1114 <br />commissary ow er shall no y the EHD immedia <br />Signature <br />CiElectrical hook-ups <br />i"Toilet and handwashing <br />izt' Potable water <br />p<ehicle wash <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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />25000613