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tely. <br />M44, Date 08/29/2024 Ok <br />er sh commissary <br />Signature <br />tify the EHD imm <br />;„.0e.IN t <br /> <br />..er— AN jo A oui N <br /> <br />f "Ir 4 <br />" 1411 COUNTY-- <br />it woo?' <br /> Greatness grows !, <br />Environmental Health Department <br />SALVADOR BUENROSTRO <br />DBA CALIFORNIA CATERING TRUCK WASH <br />730 S CALFORNIA ST <br />STOCKTON, CA 95203 <br />COMMISSARY AGREEMENT <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 />To be completed by APPLICANT <br />Business Name MANGI DA DHABA <br />Owner/Operator Name DEEPIKA PAUL <br />Business Mailing Address 2144 RIVER WILLOW AVE <br />City MANTECA StateCA Zip 95377 Bus. Ph. 3475276667 Alt. Ph. <br />I, Th-e Pc(A.-0 hereby state that the above information is current, true and correct to <br />the best of my knowledge and agree to utilize my appreved 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 pen ties. <br />Signature <br />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 />Et Wastewater disposal <br /> <br />Et 3-compartment sink <br /> GI Electrical hook-ups <br />Ef Solid waste disposal <br /> <br />12 Food preparation <br /> 12 Toilet and handwashing <br />E3 Hot & Cold water for cleaning <br /> Er Store refrigerated food <br /> Et Potable water <br />0 Store dry food/supplies <br /> <br />Er Overnight parking <br /> 13 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 t9 compl with the conditions this agreement, or if this agreement is modified or cancelled, the <br />Lic. Plate # 4NV4599 <br /> <br />4 - <br /> <br />Date 08/29/2024 <br /> <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 />RENS Signature Date <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />2S alpi-0