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SAN JOAQUIN <br /> <br />EnvirOmental Health Department <br />LOUNlv <br />SALVADOR BUENROSTRO <br />CALIFORNIA CATERING TRUCK WASH UBA COMMISSARY AGREEMENT 730 S CALFORNIA ST <br />STOCKTON, CA 95203 <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 House of Ice Cream Lic. Plate # 4RX9132 <br />Mobile Food Facility Caterer <br />Owner/Operator Name Roderick Tyler <br />Business Mailing Address 950 S Garfield St #15 <br />City Lodi StateCA Zip 95240 Bus. Ph. 209-278-6096 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 permit holder must notify the EHD. Failure to notify this office may result in permit <br />revocation and penalties. <br />Signature Date 8/19/24 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name California Catering Truck Wash <br />Address 730 S California St <br /> <br />FA# 209-464-9707 <br />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 <br />3-compartment sink <br />Electrical hook-ups <br />Solid waste disposal <br />Food preparation gr Toilet and handwashing <br />.J Hot & Cold water for cleaning V Store refrigerated food Potable water <br />s/ Store dry food/supplies V Overnight parking 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 />commissary owner shall notify the EHD immediately. <br />Signature Date 8/19/24 <br />3. To be completedby the ENV HE-ALTH 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.org/ehd <br />L-kpliCAO