Laserfiche WebLink
SAN)JOAOUIN <br />—COUNTY— <br />(". <br />Grccitness giows <br />Environmental Health Department <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 a <br />To be completed by APPLICANT <br />Business Name Ramon Guerrero dba T. El Grullense Lic. Plate # 4Y93871 <br />Owner/Operator Name Ramon Guerrero <br />Business Mailing Address 1331 S. Wilson Way <br />9-0921 City Stockton State CA Zip 95205 Bus. Ph. (209) 96 Alt. Ph.(209)740-2844 <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 (END) 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 pe);:ile s. <br />agleOt <br />To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Ramon Guerrero dba T. El Grullense <br />Address 1331 S. Wilson Way <br /> <br />Bus. Phone (209) 969-0921 <br /> <br />City Stockton Zip 95205 Owner/Operator Ramon Guerrero <br />Check all appropriate services provided: <br />id Wastewater disposal 16 3-compartment sink a Electrical hook-ups <br />Er Solid waste disposal Sr Food preparation Er Toilet and handwashing <br />6( Hot & Cold water for cleaning at Store refrigerated food GYPotable water <br />2( Store dry food/supplies Er Overnight parking 0 Vehicle wash <br />I, Ramon Guerrero , 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 <br />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 />REHS 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 />Ramon Guerrero <br />Signature Date <br /> <br />FA#