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SAN 10 A g U I N Environmental Health Department <br /> COi. P ! `r — <br /> COMMISSARY AGREEMENT <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 Tagueria EI Bolo Lic. Plate# 19399 <br /> Owner/Operator Name Aaron Cazares <br /> Business Mailing Address 2050 Madrid Dr <br /> City Stockton State CAZip 95205 Bus. Ph.209 636 3553 Alt. Ph. 209 636 3571 <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 ih CV Of �' �L��S Date 12/21/2021 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name California Catering Truck Wash FA# 209 464 9707 <br /> Address 730 S. California Bus. Phone 209 464 9707 <br /> City Stockton Zip95203 Owner/Operator Salvador Buenrostro <br /> Check all appropriate services provided: <br /> dWastewater disposal Or-3-compartment sinkZT`Electrical hook-ups <br /> Solid waste disposal 13"food J <br /> ood preparation 1;7 Toilet and handwashing <br /> El"Hot & Cold water for cleaning More refrigerated food Cr Potable water <br /> id Store dry food/supplies t21Overnight parking O 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 wrier all notify the EHDmediately. <br /> Signatu IVI �v 4 Ra.�p Date 12/21/2021 <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. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd, <br />