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Environmental Health Department <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 />NaitTai'sBusiness Name Lie. Plate # <br />510-294-8204 209-237-295395377CityZipBus. Ph.Alt. Ph. <br />12/18/2025zDate <br />2. To be completed by COMMISSARY QWNER/QPERATOR <br />FA# 0018121 <br />Bus. Phone 209-914-7966 <br />0wner/Operator Reulilyn Pangaliman <br /> Vehicle wash <br />Date 10/17/2025 <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 />El Electrical hook-ups <br /> Toilet and handwashing <br /> Potable water <br />Commissary Name Tracy Quickly <br />Address 2251 W Grant Line Rd Ste. 128 <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 />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br />Jonathan Guy/NaiTai's <br />2251W Grant Line Rd #128 <br />SANJOAOUIN <br />-COUNTY— <br />Greotness grows here. <br />City Tracy Zip 95377 <br />Check all appropriate services provided: <br /> Wastewater disposal <br /> Solid waste disposal <br />El Hot & Cold water for cleaning <br />El 3-compartment sink <br />El Food preparation <br />El Store refrigerated food <br /> Overnight parking <br />I, Reulilyn Pangaliman 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 />S i g n at u re { <br />Owner/Operator Name <br />Business Mailing Address <br />State CA <br />|t Uuy , 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