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SAN-JOAQUIN Environmental Health Department <br />—COUNTY -- <br />COMMISSARY AGREEMENT <br />Mobile Food Facility * Caterer <br />Complete sections > 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 Tacos Grullo Lic. Plate # 4Z72324 <br />Owner/Operator Name Griselda Nava <br />Business Mailing Address 929 Dewit Ct <br />City Stockton State CA Zip95210 Bus. Ph. 209 373 5366 Alt. Ph. <br />1'21 6 e I Ce K4 a(fCti hereby state that the above information is current, true and correct to <br />the best kn <br />of my owledge 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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br />CommissaryName Califomia Catering Truck Wash FA# 209 464 9707 <br />Address 730 S California St Bus. Phone 209 464 9707 <br />City Stockton Zip 95203 Owner/Operator Salvador Buenrostro <br />Check all appropriate services provided: <br />ff"Wastewater disposal Q 3 -compartment sink O'Electrical hook-ups <br />Solid waste disposal C)�'Food preparation [" Toilet and handwashing <br />G./Hot & Cold water for cleaning 1;VStore refrigerated food CVPotable water <br />0 Store dry food/supplies CrIovernight parking 6 Vehicle wash <br />I, , 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 o ner shj�II noti the EHD i ediateIy. <br />Signature EN a 1�'ay (1(� Y� � vug= 6 Date 11/1/2021 <br />13. To be completed by the ENV HEALTH iurisdiction outside of San Joaquin Co. I <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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />