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SAN J OA Q U I N Environmental Health Department <br /> _ i ; i <br /> SALVADOR BUENROSTRO <br /> COMMISSARY AGREEMENT DB' CALIFORNIA oCKWASH� ST <br /> Mobile Food Facility o Caterer STOCKTON,CA 95203 <br /> omolete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete secticr, ?. <br /> 1 . To be completed by APPLICANT <br /> usiness Name Taquizas Donaji Lic. Plate# 4HS8527 _ <br /> Dwner/Operator Name Ruby Acosta Ruiz / Armida Judith Reyes <br /> Business Mailing Address 2435 Laguna Ct <br /> ;it Stockton StateCA Zip 95206 Bus. Ph. 408-854-2082 Alt. Ph. <br /> hereby state that the above information is current,true and correct tc <br /> ;he best of my knowiedge 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 otify the EHD. Failure to notify this office may result in permii <br /> +'5vocation and nalties. <br /> 3ignature� �! �/ Date 6/19/24 <br /> ?. To be completed by COMMISSARY OWNER/OPERATOR <br /> ,;ornmissary Name California Catering Truck Wash FA# 209-464-9707 <br /> hddress 730 S California St Bus. Phone 209-271-1741 <br /> "ity Stockion Zip 95203 Owner/Operator Salvador Buenrostro & Carmen PJ%sera <br /> all appropriate services provided: <br /> Wastewater disposal 12 3-compartment sink a Electrical hook-ups <br /> Solid waste disposal 1' Food preparation 9 Toilet and handwashin,; <br /> Not & Cold water for clearing 1' Store refrigerated food g Potable water <br /> �7 Store dry food/supplies 62 Overnight parking 9 Vehicle wash <br /> hereby state that the information I have provided is current, true _:n <br /> correct to the best of my know' dge, and meets the California Health&Safety Code requirements. If the food facility <br /> cperator fails to comply w" t conditions of this agreement, or if this agreement is modified or cancelled,. :;a <br /> commissary ow shall r ti <br /> e EHD an ely. <br /> ignature Date 6/19/24 <br /> 3. To be completed by the EW HEALTH jurisdiction outside of San Joaquin Ce. j <br /> he 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 'Ith . <br /> :above commissary. Please notify EHD if the status e,their operating permit changes. <br /> R'EH'S Signature Date <br /> '368 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br /> PR Z� 002-11 <br />