Laserfiche WebLink
' a SA610ANIN Environmental Health Department <br /> r_.<lt_' —COUNTY— <br /> Greatness grows here. <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 /> 1,.To be completed by APPLICANT ; <br /> 0 <br /> Business Name Ramon Guerrero dba T. El Gruliense Lic.Plate# � <br /> Owner/Operator Name Ramon Guerrero <br /> Business Mailing Address 1331 S.Wilson Way <br /> City Stockton State CA Zip 95205 Bus. Ph. (209)969-0921 Alt. Ph.(209)740-2844 <br /> I, 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 pe 'rt older must notify the EHD. Failure to notify this office may result in permit <br /> revocation and alfies. <br /> Signature Date <br /> Date ! _ <br /> •2. To beCompleted by COMMISSARY OWNER/OPERATOR '` - - <br /> Commissary Name Ramon Guerrero dba T.EI Gruilense FA# <br /> Address 1331 S.Wilson Way Bus. Phone (20 9)969-0921 <br /> City Stockton Zip 98205 Owner/Operator Raawn Guerrero <br /> Check all appropriate services provided: <br /> g f Wastewater disposal 'Ed 3-compartment sink Electrical hook-ups <br /> WSolid waste disposal St Food preparation ErToilet and handwashing <br /> 6Y Hot&Cold water for cleaning Rf Store refrigerated food GYPotabie water <br /> If Store dry food/supplies WOvemight parking O 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. Tobe corgi' leted b 'the.I=NV F#EALTH jurisdiction oUWde of Sat `Joa uin 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 <br /> the status of their operating permit chang sf� <br /> REHS Signature,y //. jo 9��z i. Dater Y� <br /> 1868 E. Hazelton Avenue I Stockton,California 952051 T 209 48&34201 F 209 464-0138 1 www.sigov.org/ehd <br />