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�(2, OS4 �- �Q1 <br /> u' <br /> -� SAN.AAQUIN Environmental Health Department <br /> COUNTY- <br /> Greatness qro vs <br /> SALVADOR SUENROSTRO <br /> 08A CALIFORNIA CATEF31NG TRUCK WASH <br /> COMMISSARY AGREEMENT 0 8� ,G o� <br /> Mobile Food Facility ♦ Caterer <br /> Complete sections 7 and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> '...To be'c©mpleted by APPLICANT <br /> Business Name Crepetea CO _ ,_Lic. Plate# 4KJ9730 <br /> Owner/Operator Name Tran Tam Thanh _ <br /> Business Mailing Address 10136 Blue Anchor Ln <br /> City Stockton StateCA Zip 95219 Bus. Ph. 209-200-6190 Alt. Ph. <br /> I, , 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 314126 <br /> 2. TO be completed by COMMISSARY OVIINERIOPERATORAN fKa <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 /> ® Wastewater disposal 62 3-compartment sink 67 Electrical hook-ups <br /> Q Solid waste disposal Q' Food preparation 0 Toilet and handwashing <br /> ® Hot & Cold water for cleaning U Store refrigerated food R Potable water <br /> ® Store dry food/supplies B Overnight parking Q' Vehicle wash <br /> I, 1 _, hereby state that the information I have provided is current, true and <br /> correct to the best my knowledge, and meets the Ca' rnia Health &Safety Code requirements. If the food facility <br /> operator fails to mply with the c itions of thi greement, or if this agreement is modified or cancelled, the <br /> commissary ow II notify t D i edi <br /> Signature T _ —Date 314/26 <br /> letilr�'bythe_EN HEALTH jurisdiction_ outside:of:San Joagwin.,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 Signature Date <br /> 1868 E. Hazelton Avenue i Stockton, California 96205 i T 209 468-3420 i F 209 464-0138 E www.sjgov.org/ehd <br /> S <br />