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SAN 10AQUIN 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 Kenston Farms Lic. Plate# IN 3173846 <br /> Owner/Operator Name Dein Byrd - Salesman / Sarah Preston - Chief Operations Officer <br /> Business Mailing Address 1053 Commerce Blvd <br /> City Pelham State AL Zip 35124 Bus. Ph.256-404-1415 Alt. Ph.� <br /> Sarah Preston (COO) 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 1` �� i r.lr4� -- _-- —Date 02/05/2025 <br /> 2. To be completed by COMMISSARY OWNERI_OPERATOR <br /> Kettleman Station <br /> Commissary Nage �UL�� _ FA# <br /> Address 400 East Kettleman Lane, Lodi, CA, 95240 Bus. Phone C909 -C��=Eon I__ <br /> City Lodi Zip 95240 Owner/Operator <br /> Check all appropriate services provided: <br /> ❑ Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation Toilet and handwashing <br /> ❑ Hot& Cold water for cleaning ❑ Store refrigerated food 13Potable water <br /> ❑ Store dry food/supplies N/Overnight parking ❑ Vehicle wash <br /> hereby stale that the information I have provided is current,true and <br /> correct to the best of my kA wledge,and Vets 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 cad <br /> F3. To be Completed by the ENV HEALTH j risdiction 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 l Stockton, California 95205 I T 209 468-3420 i F 209 464-0138 i www.sjgov.org/ehd <br /> 1 25DO,3LAS <br />