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---W� S A N J O A Q U I N Environmental Health Department <br /> COUNTY <br /> Greatness grows here. SA, VADOR BUENRO—STRO <br /> DBA CALIFORNIA CATERING TROCK WASH <br /> 730 8 CALFQRNIA gT <br /> COMMISSARY AGREEMENT STOCKTON,CA 96203 <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 El Pirol Lic. Plate# 4VN3625 <br /> Owner/Operator Name David Valdenegro Liera �l LQg T F,,5 s vy 8- t- 1 T2. l`o�--O <br /> Business Mailing Address_ 101 C ra r-t W V <br /> City ManteSa StateCA Zip 95336 Bus. Ph. 269�1:0-8672 Alt. Ph. <br /> hereby state that the above information is current, true and correct to <br /> Ifbest of my knowledge and agree to utilize my approved commissary in accordance with California Health & <br /> ety 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 nal ' <br /> Signature Date 511126 <br /> 2. To completed by COMMISSARY OWNEMPERATOR <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 /> 12 Wastewater disposal 12 3-compartment sink r4 Electrical hook-ups <br /> 1l Solid waste disposal 12 Food preparation 9 Toilet and handwashing <br /> 0 Hot & Cold water for cleaning (3 Store refrigerated food 1R Potable water <br /> 0 Store dry food/supplies 0' Overnight parking CY Vehicle wash <br /> 1, , 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 comply with the conditions of this agreement, or if this agreement is modified or cancelled, the <br /> commissa ner sh I notify the EHD imm tely. <br /> Signature Date 511126 <br /> 3. To be com lee b 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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />