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SAN JOAQUIN Environmental Health Department <br /> COUNTY <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 /> Business Name Ian's Pork BBQ LLC Lic.Plate# <br /> Owner/Operator Name Janette Escobal <br /> Business Mailing Address 25164 Copa Del Oro Dr_ #201 <br /> City Hayward State-CA-Zip-2A645--Bus. Ph. (510)415-7484 Alt. Ph.(510)565-5735 <br /> I, Janette Escobal 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 (f. C<a.2 Date4/20/2022 <br /> 2, To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Leia's FA# <br /> Address 2706 Pavillion Parkway Bus. Phone (209)756-1897 <br /> City Tracy Zip95376 Owner/Operator DJ Miller <br /> Check all appropriate services provided: <br /> p Wastewater disposal O 3-compartment sink O Electrical hook-ups <br /> p Solid waste disposal 13 Food preparation O Toilet and handwashing <br /> 17 Hot&Cold water for cleaning E3 Store refrigerated food O Potable water <br /> O Store dry food/supplies E3 Overnight parking E3 Vehicle wash <br /> DJ Miller , 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 amok Date Apr 21,2022 <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 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />