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S A N J O A Q U I N Environmental Health Department <br /> COUNTY <br /> r <br /> l�f'N{linFSS OF ti` '•ire <br /> MLVADOR BUENROSTRO <br /> COMMISSARY AGREEMENTDaacALIFORNIA CATERING TRUCK WASH <br /> Mobile Food Facilityo Caterer T 5 TON,CALF C 9520 <br /> STOCKT(}N,CA 95203 <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 Tandoori & Tawa Dhaba LLC Lic. Plate# 4EM3326 <br /> Owner/Operator Name Jas ai Singh <br /> Business Mailing Address 519 Olivine Ave <br /> City Lathrop State CA Zip 952330 Bus. Ph. 209-400-1576 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 -co,& , Date 1/23/25 <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 /> Q Wastewater disposal 112 3-compartment sink Q' Electrical hook-ups <br /> U Solid waste disposal (2 Food preparation 12 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning 17 Store refrigerated food U Potable water <br /> if Store dry food/supplies 19 Overnight parking ®' Vehicle wash <br /> I, , hereby state that the information I have provided is current, true and <br /> correct to the best of y knowledge, and meets the California Health&Safety Code requirements. If the food facility <br /> operator fails to c ply with the co itions of thi Bement, or if this agreement is modified or cancelled, the <br /> commissary own hall notify th HD immediat <br /> Signature Date 1/23/25 <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />