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Environmental t-laalth npn�)rtnu---' <br /> SALVADOR BUENROSTRO <br /> DBA CALIFORNIA CATERING TRUCK WAS{ <br /> 730 S CALFORNIA ST <br /> COMMISSARY AGREEMENT STOCKTON,CA 95203 s <br /> .�... _ . <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 LAS REINAS FOOD SHOP Lic. Plate# 4UC8220 <br /> Owner/Operator Name YERALDIN E. RANGEL G. <br /> Business Mailing Address 1856 E. FLORA ST#1 <br /> C�iit--y STOCKTON State CAZip 95205 Bus. Ph. 2092713292 Alt. Ph. <br /> 1tao��Q_ I�hereby state that the above information is current, true and correct to <br /> the best of my knowledge aid 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 pe 't holder mu t notify the EHD. Failure to notify this office may result in permit <br /> revocation and pe i alties. <br /> Signature d Date 4/18/22 <br /> 2. To be leted by COMMISSARY OWNER/OPERATOR <br /> Commissary Name CALIFORNIA CATERING TRUCK WASH FA# <br /> Address 730 S CALIFORNIA ST Bus. Phone 2092711741 <br /> City STOCKTON Zip 95203 Owner/Operator SALVADOR BUENROSTRO <br /> Check all appropriate services provided: <br /> /Wastewater disposal Z3-compartment sink electrical hook-ups <br /> zOlid waste disposal /Food preparation /Toilet and handwashing <br /> ot & Cold water for cleaning -/Store refrigerated food �P table water <br /> Store dry food/supplies /Overnight parking /Vehicle wash <br /> I, , hereby slate 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 o this agreement, or if this agreement is modified or cancelled, the <br /> commissa o ner s II notify the EHD immafiihtely. <br /> Signature _Date 4/18/22 <br /> V1 — <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 />