Laserfiche WebLink
_ <br /> � � &� 8� � U8k&K Environmental U������ �����a��.emt <br /> ~~r"."��w,��.�~°o°v -- -- �� Department <br /> ���� <br /> SALVADOR13UENROSTRD <br /> UBACALRJANACATEAN0TRUCK WASH <br /> 730 CALFORN|A ST <br /> BTOCKTDN,CA 95203 <br /> � <br /> COMMISSARY AGREEMENT f� <br /> Mobile Food Facility + c8tBnB[ <br /> Complete sections Yand 2. If your commissaty is located outside of San Joaquin County also complete section 3. <br /> Business Name |o. Plats <br /> Name Jesus Valencia <br /> Business Mailing Address <br /> Ci StateCA Zipun. ph. 209-981-6800 |t. ph. <br /> | hereby state that the above information iacurrent,true and correct to <br /> the best ofmy knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> 3o[e(y Code. and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the <br /> commissary i t notify EH�. Failure may <br /> Signaturerevocation and On�atiqs. <br /> �����__����__Oat ' <br /> /25/26 <br /> 12. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name FA9- 209-464-9707 <br /> Address 730 S California St Bus. Phone <br /> Cit |p 95203_Owner/Operator Salvador Buenrostro & Carmen Rivera <br /> Check all appropriate services provided: <br /> 13 Wastewater disposal CZ 3-uonnpartrnent sink Ct Boctdcm| hook-ups <br /> E3 Solid waste disposal 112Food preparation DToilet and handvvaohing <br /> 8 Hot & Cold water for cleaning M Store refrigerated food 12 Potable water <br /> El Store dryfood/supp|ies [7 Overnight parking ~~U� <br /> Veh�o|evvash <br /> |. ' hereby state that the information | have provided in vunnnt, true and <br /> correct to the b d t \h California Health &Safety Code requirements. If the food facility <br /> operator fails to y <br /> with the conditions of th's agre)oent, or if this agreement is modified or cancelled, the <br /> commissary 0 hall notify the EHP1r dfately. <br /> V VVI/ <br /> MOMM <br /> The oomm�aamry is located in County. The above food facility meets the <br /> commissary requirements in California Health & Safety Code. The above checked oomioen are available at the <br /> above commissary. Please notify EHDifthe status oftheir operating pannitchanges. <br /> REHS Bignmiu Date <br /> 1888E. Hazelton Avenue | Stockton, CaUyomm|m85205 | T 209468~34201 F 209 464-0138 | vm^mv.migouorg/ehd <br /> �n � �0 <br /> � �� �� �_ 1 <br />