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Environmental Health Department <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 Lie. Plate#11937T3 <br />Alt. Ph. <br />Date 11/18/25 <br />| 2. To be completed by COMMISSARY OWNER/OPERATOR <br />FA# 209-464-9707California Catering Truck Wash <br />209-271-1741Bus. Phone <br />Owner/Operator Salvador Buenrostro & Carmen RiveraStockton95203 <br />ET Vehicle wash0 <br />11/18/25Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />Date REHS Signature <br />ET <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 />O' Electrical hook-ups <br />O’ Toilet and handwashing <br />e Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420) F 209 464-0138 | www.sjgov.org/ehd <br />SAN JOAQUIN <br />— COUNTY------ <br />Greatness grows here. <br />City Stockton Zip <br />Check all appropriate services provided: <br />Wastewater disposal <br />Solid waste disposal <br />Hot & Cold water for cleaning <br />Store dry food/supplies <br />Nana's Capital LLC <br />Owner/OperatorName Stephanie Lopez <br />Business Mailing Address 3218 Ripplerock Lane <br />City Stockton State CA Zip 95206 Bus. Ph. 2095390693 <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 <br />„ 3/LlvADOR BUENROSTRO <br />DBA GALIFOHNIA CATERING TRUCK WASH <br />S CAL.FORNIA ST <br />STOCKTON, CA 95203 <br />O' 3-compartment sink <br />O’ Food preparation <br />O' Store refrigerated food <br />O' Overnight parking <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 failsHp comply with the conditions 6f this agreement, or if this agreement is modified or cancelled, the <br />commissaryijwner shall notify the EHD immediately. <br />Signatu re | t <br />Commissary Name <br />Address 730 S California St