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2SODI <br />SAN JOAQUIN <br /> <br />Environmental Health Department <br />COUNTY <br />Greatness grows horr- <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 />To be completed by APPLICANT <br />Business Name Jabs Mexican Food <br />Owner/Operator Name Edgardo Reynoso <br />Business Mailing Address 25456 S. Schulte RD. <br />City Trany State c,A ZIP 9S177 <br /> <br />Lic. Plate # 8Kn7825 <br /> <br />Bus. Ph. 2nqsgqn6R4 <br /> <br />Alt. Ph. 2ncis7q22q2 <br /> <br />Frigardn Reynnsn , 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 Date 11/15124 <br />To be completed by COMMISSARY OWNER/OPERATOR <br />.12-J <br />Address -camp — 2- C < k-3 Snc),('-t Bus. Phone 2098308066 <br />City V.--2,--e--(;) Zip le) 73 ---?-7 Owner/Operator Edgardo Reynoso <br />Check all appropriate services provided: <br />Wastewater disposal <br /> O 3-compartment sink <br /> O Electrical hook-ups <br />13 Solid waste disposal <br /> O Food preparation <br /> O Toilet and handwashing <br />Hot & Cold water for cleaning O Store refrigerated food <br /> O Potable water <br />Store dry food/supplies <br /> O Overnight parking <br /> O Vehicle wash <br />I, Fdgardo Reynoso , 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 11/15/24 <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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd <br />Commissary Name .inins mexican Fmd FA#