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Environmental Health Department <br />Gr <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 />Brix Entertainment Inc.Business Name Lie. Plate# <br />Brad West <br />2044 Brocchini Ln <br />95337 Alt. Ph. <br />9-8-25Date <br />Chapter 2 FA# <br />2-0^ • S8 ll95376 <br /> Vehicle wash <br />I, <br />9/8/25DateSignature. <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />Date REHS Signature. <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <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 /> Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />SAN JOAQUIN <br />------COUNTY— <br />Commissary Name. <br />Address 88 w 10th St <br />Tracy <br />2Jo be completed by COMMISSARY OWNER/QPERATQR_______________ <br />poo S'Z BY <br />_________Bus. Phone (209) 855-1485 <br />Owner/Operator Heather Smiddy <br />R 3-compartment sink <br />E Food preparation <br />El Store refrigerated food <br /> Overnight parking <br />, 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 />Uxtr <br />City "dCy Zip. <br />Check all appropriate services provided: <br /> Wastewater disposal <br />0 Solid waste disposal <br />El Hot & Cold water for cleaning <br />KI Store dry food/supplies <br />Heather Smiddy <br />Bus. ph.209-740-7651 <br />Owner/Operator Name <br />Business Mailing Address <br />City Manteca State CA Zjp <br />I, Brad West 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