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SI2-6b S14 Ltc(L <br />SAN JOAQUIN Environmental Health Department <br />UNTY — <br />i; I a r ❑„s>5 SALVADOR BUENROSTRO <br />to CALIFORNIA CATERING TRUCK WASH <br />73o S CALFORNIA ST <br />COMMISSARY AGREEMENT STOCKTON, CA 95203 <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 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, wi�ryla <br />ermit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation ar`'V� penalties. <br />� �� Date 2/28/23Signature U-P5V.S <br />2. To be completed by COMMISSARY OWNER/OPERATOR I <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 />12 Wastewater disposal D 3 -compartment sink D Electrical hook-ups <br />6 Solid waste disposal 9 Food preparation 12 Toilet and handwashing <br />® Hot & Cold water for cleaning GY Store refrigerated food Gi' Potable water <br />® Store dry food/supplies U Overnight parking ff 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[vpwner *all notify the EHDit'lpr mediately. <br />2/28/23 <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 <br />1868 E. Hazelton Avenue i Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www,sjgov.org/ehd <br />