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SAN J OAQ U I N Environmental Health Department <br />--COUNTY— <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 />11. To be completed by APPLICANT <br />Business Name Reyna Del Sur Lic. Plate # 2W22508 <br />Owner/Operator Name Maria Guadalupe Sanchez <br />Business Mailing Address 1620 Sikh Temple St <br />City Stockton State CA Zip 95206 Bus. Ph. 209 689 4660 Alt. 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 />SignaturekQrjQ c' "tu* SAn - Date 2/23/22 <br />2. To be completed by COMMISSARY OWNER/OPERATOR _,0 Z <br />Commissary Name California Catering Truck Wash FA# 209 464 9707 <br />Address 730 S California St Bus. Phone 209 464 9707 <br />City Stockton Zip 95203 Owner/Operator Salvador Buenrostro <br />Check all appropriate services provided: <br />B Wastewater disposal Qet-compartment sink electrical hook-ups <br />elSolid waste disposal Cloofood preparation SYToilet and handwashing <br />e of & Cold water for cleaning Store refrigerated food G�P�otable water <br />O Store dry food/supplies i�Overnight parking W3 ehicle wash <br />I, , 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 />commissary qvner shall notify the EHD imrggdiately. <br />JI'O17G1'JI W. !41IMI/.I/AUSEMMEM•A <br />13, To be comaleted by the ENV HEALTH iurisdiction 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 Siqnature Date <br />1868 E. Hazelton Avenue 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />