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L C <br /> SAN JOAQUIN Environmental Health Department <br /> C r)iJ N Y— <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility* Caterer <br /> Complete sections f 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 Taaueria EI Bolo Lic. Plate# 19399 <br /> Owner/Operator Name Aaron Cazares <br /> Business Mailing Address 2050 Madrid Dr <br /> City Stockton State CAZip95205 Bus. Ph.209 636 3553 Alt. Ph. 209 636 3571 <br /> 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 0 tti Oj� (20-2G,ILS Date 12/21/2021 <br /> 2.To be corn leted':b fiSCa b PAF Y-ENO TQRx <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 Imo-compartment sink electrical hook-ups <br /> p Solid waste disposal 13 Food preparation Toilet and handwashing <br /> O Hot& Cold water for cleaning store refrigerated food Cr Potable water <br /> t3 Store dry food/supplies U Overnight parking 0 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 falls to comply with the conditions of this agreement, or if this agreement is modified or cancelled; the <br /> commissary wner�Ii1 a�l,l,n'o�t^ify� the EHD mediately. <br /> Signature 11 411V A (J ;�/� Date 12121/2021 <br /> �' v <br /> 3. To be completed by the ENV '9AH4c (a.n,outsl�de <br /> of S <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 /> y. <br />