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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 />Alt. Ph. <br />Owner/Operator <br /> Vehicle wash <br />o2Date <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 />FfesoCW <br />FA#___________ <br /> Electrical hook-ups <br />k/Toilet and handwashing <br /> Potable water <br />COMMISSARY AGREEMENT <br />Mobile Food Facility ♦ Caterer <br /> 3-compartment sink <br /> Food preparation <br /> Store refrigerated food <br />5/Overnight parking <br />, hereby state that the information I have provided is current, true and <br />ets the California Health & Safety Code requirements. If the food facility <br />Date 02/05/2025 <br />SAN JOAQUIN <br />COUNTY- <br />Greilfntss (>rok7$ htii. <br />Business NameKenston Farms Lie. Plate# IN 3173846 <br />Owner/Operator Name Devin Byrd - Salesman / Sarah Preston - Chief Operations Officer <br />Business Mailing Address 1053 Commerce Blvd <br />CjtvPelham StateAL Zip35124 Bus. Ph.256-404-1415 <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. V <br />Signature ____Uuw <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary Name Kettleman Station z __ <br />Address 400 East Kettleman Lane, Lodi, CA, 95240 Bus. Phone <br />City Lodi Zip95240 <br />Check all appropriate services provided: <br /> Wastewater disposal <br /> Solid waste disposal <br /> Hot & Cold water for cleaning <br /> Store dry food/supplies <br />correct to The best of my khdwledge, and rpXets <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 <br />j 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.