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'SAN-,JOAQUIN Environmental Health Department <br />--COU NTY— <br />Greatness grovis 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 />11. To be completed by APPLICANT <br />Business Name Taloa's Bakery Lic. Plate <br />Owner/Operator Name Mariah Taloa <br />Business Mailing Address 1709 Cameo Drive <br />City Stockton State CA Zip 95206 Bus. Ph. 209-237-6543 Alt. <br />I, Mariah Taloa , 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 />revocation and penalties. <br />Signature=4lt,`bie's. Date 11/8/2021 <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Stockton Community Kitchen FA# <br />Address -1 10 N EI Dorado Street Bus. Phone <br />City Stockton Zip 95202 Owner/Operator Rima Barkett <br />Check all appropriate services provided <br />13 <br />Wastewater disposal <br />0 3 -compartment sink <br />IN Electrical hook-ups <br />N <br />Solid waste disposal <br />61- Food preparation <br />dM Toilet and handwashing <br />® <br />Hot & Cold water for cleaning <br />Store refrigerated food <br />® Potable water <br />135 <br />Store dry food/supplies <br />0 Overnight parking <br />17 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 owner sW ngfify the EHD immediately. <br />3. 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />