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SAN J OAQU I N Ent'vironmental Health Department <br /> C O u hr i Y----- <br /> SALVADOR BUENROSTRO <br /> DBA CALIFORNIA CATERING TRUCK WASH <br /> 730 S CALIFORNIA S T <br /> COMMISSARY AGREEMENT STOCI4TON,CA95203 <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. To be completed by APPLICANT <br /> Business Name Family#2 Lic. Plate # 4SZ2639 <br /> Owner/Operator Name Graciela Santillan Ramirez <br /> Business Mailing Address 2828 S B St <br /> City Stockton State CA Zip 95206 Bus_ Ph. 209-342-8958 Aft. Ph. <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 y' r G` �� Date 718126 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary dame 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 /> U Wastewater disposal J 3-compartment sink �k Electrical hook-ups <br /> ,7 Solid waste disposal ;r Food preparation ice! Toilet and handwashing <br /> Hot & Cold water for cleaning ✓ Store refrigerated food r✓ Potable water <br /> Store dry food/supplies Overnight parking f' Vehicle wash <br /> 1, hereby'�4a�e that the information i have provided is current,true and <br /> correct to the be f my knowledge,and meets the Ga' rnia Health &Safety Code requirements. If the food facility <br /> operator fails t� omply with the riditions of th greement, or if this agreement is modified or cancelled, the <br /> commissary o n r I notify t o HD immedi <br /> Signature f Date 718126 <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 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. Hezelton Avenue I Stockton, California 95205 1 T 209 46B-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> PR0sq IL-W <br />