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�AQ �N Pnvironmental Health Depart:m� <br /> COUNTY <br /> SALVADOR BUENROSTRO <br /> «p.,P LAFORNIA CATERING TRUCK WASH <br /> I30 S CALFORNIA ST <br /> COMMISSARY AGREEMENT STOCkTON,CA95203 <br /> Mobile Food Facility e Caterer <br /> Complete sections 9 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 BIRRIERIA Y TAQUERIA LOS MATADOS Lic. Plate# 4MD2051 <br /> Owner/Operator Name JESUS A. HERNANDEZ <br /> Business Mailing Address 2705 W. ALPINE AVE <br /> City STOCKTON StateCA Zip Bus. Ph. 2096880033 Alt. Ph. <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 ermit holder must notify the EHD. Failure to notify this office may result in permit <br /> revocation a penalties. <br /> Signature ` v-S lel tt a r � Date 2/28/23 <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 St Bus. Phone 209-271-1741 <br /> City Stockton Zip 95203 Owner/Operator Salvador Buenrostro & Carmen Rivera <br /> Check all appropriate services provided: <br /> ®' Wastewater disposal Ck 3-compartment sink U Electrical hook-ups <br /> ®' Solid waste disposal GY Food preparation <br /> Q Toilet and handwashing <br /> ® Hot & Cold water for cleaning 12 Store refrigerated food U Potable water <br /> M Store dry food/supplies [7 Overnight parking U Vehicle wash <br /> , 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 wner all notify the EHD mediately. <br /> Signature <br /> Date 2/28/23 <br /> 3. To be com leted b the NV 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 1 Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />