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= SAN.>410AQUIN Environmental Health Department <br /> l_'I —COUNTY— <br /> Greatness grows here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility♦ Caterer <br /> Complete sections i and 2. If your commissary is located outside of San Joaquin County also complete section 3. <br /> I. To be Completed by APPLICANT <br /> Business Name Ramon Guerrero dba T.EI Grullense Uc.Plate# <br /> Owner/Operator Name Ramon Guerrero <br /> Business Mailing Address 1331 S.Wilson Way ` <br /> City Stockton State CA ZipA§20_Bus. Ph. (209)9694921 Alt. Ph.(209)740-2844 <br /> 1, 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. It the use of the <br /> commissary is discontinued,the pern,'t older must notify the EHD. Failure to notify this office may result in permit <br /> revocation and sit,*$. <br /> Signature G � !'L Datev(;/C� <br /> 2, To be Completed by COMMISSARY OWNERIOPERATOR ' <br /> Commissary Name Ramon Guerrero dba T. EI Grullense FA# <br /> Address 1331 S.Wilaon Way Bus. Phone(209)969-0921 <br /> City Stockton Gip 98205 Owner/Operator Ramon Guerrero <br /> Check all appropriate services provided: <br /> g f Wastewater disposal ild 3-compartment sink GY Electrical hook-ups <br /> W Solid waste disposal 9�Food preparation ErTollet and handwashing <br /> 57'Hot&Cold water for cleaning R(Store refrigerated food WPotable water <br /> d Store dry food/supplies WOvernight parking C3 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 EHO immediately. <br /> Signature Date <br /> 3. To tie corn leted:;b"the.ENV HE-ALTH 'urisdiaGon bifte o-San-Joa Uin Co. <br /> _jdThe 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 Chang . <br /> t r 0 -j <br /> REHS Signature ��a�s<!Ij,C�'rr' a'tizl? ss Oate <br /> 1868 E. Hazelton Avenue I Stockton,California 95205 I T 209 468-34201 F 209 464-0138 l www.sjgov.orglehd <br /> C' <br /> i <br />