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vner s A - commissary o itSignature , Date 8/15/24 1/1 ll notify the EHD i ediately. VIV4 • SANAOAQUIN Environmental Health Department COUNTY- SALVADOR BUENROSTRO COMMISSARY AGREEMENII2A CALIFORNIA CATERING TRUCK WASH 730 S CALFORNIA ST Mobile Food Facility • Caterer STOCKTON, CA 95203 Complete sections 1 and 2. If your commissary is located outside of San Joaquin County also complete section 3. To be completed by APPLICANT Business Name Antojitos Camacho Lic. Plate # CART Owner/Operator Name Carlos Camacho Business Mailing Address 438 N Golden Gate City Stockton StateCA Zip 95205 Bus. Ph. 209-685-7133 Alt. Ph. , hereby state that the above information is current, true and correct to the best of my knowledge and agree to utilize my approved commissary in accordance with California Health & Safety Code, and San Joaquin County Environmental Health Department (EHD) requirements. If the use of the commissary is discontinued, the permit holder must notify the EHD. Failure to notify this office may result in permit revocation and penalti 41 kyo, To be completed by COMMISSARY OWNER/OPERATOR Commissary Name California Catering Truck Wash FA# 209-464-9707 Address 730 S California St Bus. Phone 209-271-1741 City Stockton Zip 95203 Owner/Operator Salvador Buenrostro & Carmen Rivera Check all appropriate services provided: Wastewater disposal CI 3-compartment sink Et Electrical hook-ups Ef Solid waste disposal 12 Food preparation 12' Toilet and handwashing Ea' Hot & Cold water for cleaning Er Store refrigerated food ▪ Potable water E3 Store dry food/supplies Er Overnight parking 13. Vehicle wash , hereby state that the information I have provided is current, true and correct to the best of my knowledge, and meets the California Health & Safety Code requirements. If the food facility operator fails to comply with the conditions of this agreement, or if this agreement is modified or cancelled, the , Signature Date 8/15/24 3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. The commissary is located in County. The above food facility meets the commissary requirements in California Health & Safety Code. The above checked services are available at the above commissary. Please notify EHD if the status of their operating permit changes. REHS Signature Date 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd 000-1 s