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SANAAQUIN Environmental Health Department <br /> COUNTY <br /> + , - Greatness grows here. <br /> SALVADOR BUENROSTRO <br /> DsA CALIFORNIA 30SCCATERING TRUCK WASH <br /> COMMISSARY AGREEMENT <br /> 730 S CAt,FORNfA 5T <br /> Mobile Food Facility ♦ Caterer STOCKTON,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 corn leted by APPLICANT ,;. <br /> Business Name GYI/L k�'�'Lic. Plate# 4WD1376 <br /> Owner/Operator Name Mohamed Faisal Abdulla Mohsen <br /> Business Mailing Address 4514 Pissarro Dr. <br /> City Stockton StateCA Zip 95206 Bus. Ph. 209-888-4063 Alt. Ph. <br /> l° 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, thel ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation 1a d penalties. <br /> Signature l= t Date 1/16126 <br /> 2. To be completed by MMISSARY O'NNER/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 EZ 3-compartment sink Q Electrical hook-ups <br /> El Solid waste disposal Q Food preparation 6T Toilet and handwashing <br /> E3 Hot & Cold water for cleaning U Store refrigerated food U Potable water <br /> E0 Store dry food/supplies i3 Overnight parking B 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 compl"shall <br /> with the conditions of this Bement, or if this agreement is modified or cancelled, the <br /> commissaEHD immediate) <br /> Signature Date 1/16/26 <br /> leted 'Py the ENV HEALTH jurisdiction outsldd FS <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 ; T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> P�2c�D)q---4 1 <br />