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SAN 10AQUIN Environmental Health Department <br /> COUNTY <br /> DBA ALVA00p SU NROSrRO <br /> CALIFORNIAA Q4-M.RING <br /> COMMISSARY AGREEMENT STOaCKrONOA95 0r�kw, <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 /> 1. 1 . To be completed by APPLICANT <br /> Business Name Churros Veracruz Lic. Plate# CART <br /> Owner/Operator Name Saul Carvajal <br /> Business Mailing Address 15595 6th St <br /> City Lathrop StateCA Zip 95330 Bus. Ph. 209-230-7422 Alt. Ph. <br /> s <br /> I, hereby state that the above information is current, true and correct to <br /> the best of my knowledge a d 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 peQ?k4es. r <br /> Signature Y L) Date 6/3/26 <br /> 2. To be completed b 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 OwnerlOperator Salvador Buenrostro & Carmen Rivera <br /> Check all appropriate services provided: <br /> 12 Wastewater disposal 12 3-compartment sink GY Electrical hook-ups <br /> B Solid waste disposal 12 Food preparation 62 Toilet and handwashing <br /> i® Hot & Cold water for cleaning [7 Store refrigerated food G Potable water <br /> 0 Store dry food/supplies Q Overnight par ' g [3 Vehicle wash <br /> I, hereby to that the information 1 have provided is current, true and <br /> correct to the Pbef my knowledge, ndmeets the ifornia Health &Safety Code requirements. If the food facility <br /> operator failsmply with the . ` nditions of agreement, or if this agreement is modified or cancelled, the <br /> commissary o }I tify t EHD immeSignature /G 7. Date 613126 <br /> 3. To bd compAeted 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 /> P� 65Z `1� Zu <br />