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SAN J UAQU I N Environmental Health Department <br /> _C C)U Iv T Y--- <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility o 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 Devin Byrd - Salesman I Sarah Preston - Chief Operations Of>'Icer <br /> Business Mailing Address 1053 Commerce Blvd <br /> City Pelham State AL Zlp 35124 Bus. Ph.256-404-1415 Alt. Ph. <br /> I 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 J'i ' 1iij47y Date 02/05/2025 <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name Kettleman Station L r�,31"� FA# <br /> Address 400 East Kettleman Lane, Lodi, CA, 95240 Bus, Phone 0209 - ,qS()!� I <br /> City Lodi Zip 95240 Owner/Operator <br /> Check all appropriate services provided: <br /> [3 Wastewater disposal ❑ 3-compartment sink ❑ Electrical hook-ups <br /> ❑ Solid waste disposal ❑ Food preparation &(Toilet and handwashing <br /> ❑ Hot & Coldwater for cleaning ❑ Store refrigerated food ❑ Potable water <br /> ❑ Store dry food/supplies / 19Overnight parking ❑ Vehicle wash <br /> bWiri�_.l- , hereby state that the information i have provided is current, true and <br /> correct to the best of my kR 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,„ <br /> 3. To be completed by the ENV HEALTH ' risdiction outside of San Joa in 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 /> 1B68 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orgtehd <br />