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Environmental Health Department <br />Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />□'"Electrical hook-ups <br />rFToilet and handwashing <br />□^Potable water <br />S^/ehicle wash <br />O B-cpmpartment sink <br />O^Food preparation <br />□’"Store refrigerated food <br /> <5vemight parking <br />FA#_______________________ <br /> <br />Owner/Operator <br />'■ \ SANJOAOUIN <br />------COUNTY------ <br />Greqtneis grows here. <br />—i <br /> Lie. Plate# 3 45 OYZ, <br />_________________________ <br />2Z_8_________ <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 /> <br />| 1. To be completed by APPLICANT <br />Business Name_ <br />Owner/Operator Name A \ r do <br />Business Mailing Address kO- 13o X <br />City------LOk State_Cj^7ip I Bus. Ph. <br />thTT^t nf L------TO--------T------------------hereby state that the above 'nformation is current, true and correct to <br />Safetv CnL knowled9e and agree to utilize my approved commissary in accordance with California Health & <br />batety Code, and San Joaquin County Environmental Health Department (EHD) requirements If the use of the <br />ZXTd Failure t0 notify this office may result in permit <br />s'9natLjre-------------;Date S'/? / <br />~2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissarv Namp SALVADOR BUENROSTROV N DEL/\ CALIFORNIA CATERING-TRUCK WASH <br />Address 730 s CALFORNIA ST <br />---------------------------STOCKTON, CA 05203----------- <br />City Zip <br />Check all appropriate services provided: <br />^Wastewater disposal <br />Q^SoTid waste disposal <br />□jHdt & Cold water for cleaning <br />LXBtore dry food/sjjpplies <br />, 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 dkner shall notify the EHD immediately. a <br /> <br />Signaturq^y __________ <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 faci|jty 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