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! • <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 Xamira's Kitchen 4VF6013Lie. Plate# <br />Alt. Ph. <br />5/7/26Date <br />FA# 209-464-9707 <br />209-271-1741Bus. Phone <br />Stockton Owner/Operator Salvador Buenrostro & Carmen Rivera <br />S' Vehicle wash <br />REHS Signature,Date <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 ) www.sjgov.org/ehd <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 />Commissary Name <br />Address <br />S' Electrical hook-ups <br />O' Toilet and handwashing <br />O' Potable water <br />Environmental Health Department <br />SALVADOR BUENROSTRO <br />DBA CALIFORNIA CATERING TRUCK WASH <br />730 S CALFORNIA ST <br />STOCKTON, CA 05203 <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />California Catering Truck Wash <br />730 S California St <br />____________________D ate 5/7/26______________ <br />EArilVjtirisdiction outside of San Joaquin Co. <br />City Stockton Zip 95203 <br />Check all appropriate services provided: <br />Wastewater disposal <br />□T Solid waste disposal <br />S? Hot & Cold water for cleaning <br />B Store dry food/supplies <br />I, <br />Owner/Operator Name Jose Villegas <br />Business Mailing Address 5728 Doncaster Way <br />City Stockton StateCA Zip 95207 <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 M <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />SAN JOAQUIN <br />------COUNTY------- <br />Greatness grows here. <br />Bus Ph 209-483-3855 <br />£2' 3-compartment sink <br />S' Food preparation <br />S' Store refrigerated food <br />H Overnight parking <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 th^conditions of this agreement, or if this agreement is modified or cancelled, the <br />commissary ov^ier shall notifwrhe EHD immedja^ly. <br />Signature l! j <br />3. To completed by thelE