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revocation and • yite ies• ,in' Signature <br />SANAAQUIN <br />COUNTY— <br />Greorness grows here. <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 3. <br />Business Name Ramon Guerrero dba T. El Grullense Lic. Plate # 4F06291 <br />Owner/Operator Name Ramon Guerrero <br />Business Mailing Address1331 S. Wilson Way <br />969 209) -0921 City Stockton State CA Zip 95205 Bus. Ph. ( Alt. Ph.(209)740-2844 <br />Ramon Guerrero , 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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Ramon Guerrero dba T. El Grullense <br />Address 1331 S. Wilson Way <br />City Stockton Zip 95205 <br />Check all appropriate services provided: <br /> <br />Bus. Phone (209) 969-0921 <br /> <br />RamonOwner/Operator Guerrero <br /> <br />f Wastewater disposal <br /> II 3-compartment sink <br /> <br />a Electrical hook-ups <br />Ur Solid waste disposal <br /> Et Food preparation <br /> Er Toilet and handwashing <br />Et Hot & Cold water for cleaning <br /> Ri Store refrigerated food <br /> GYPotable water <br />rti Store dry food/supplies <br /> G"Overnight parking <br /> 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 />3. To bfrCbMPIetesi-by-the ENV HEALTH jurisdiction'Outside of San IJoaquin. .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 1 Stockton, California 95205 1 T 209 468-3420 I F 209 464-0138 I www.sjgov.orgiehd <br />Date 1//7)1g <br />FA#