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ENV1R0NMENTAL li EALTH <br />]THIS FORM MI ST Bl DISH * VKHITWSFKT (II SI V ON Jill PREMISES <br />Faeihty ID FAW27M1 <br />l»»t IMIfflBI <br />ACORlf CERTIFICATE OF LIABILITY INSURANCE <br />Silttrtm <br />HCLCVfW J <br />0SC22C2S <br />n»o I : <br />Mcr L— <br />rcwcrrxi <br />7T <br />QANCtllATlON <br />ACORD 2$ (201t^l|»X»*M O* «k."W <br />MKwnc-ctnu’x-onouboai.tPCU cacohd' <br />t 300 005 <br />I S OOP <br />t 1 oocooo <br />I 2000 000 <br />Rctuhicd Facility LOS PRIMOS TEX-MEX FOOD «2 (4VF5876) <br />1211 S SEVENTH ST <br />MODESTO. CA 95351 <br />BdJmf Address ATTN CARBAJAL ARMANDO <br />321 GRANADA WAY <br />TRACY, CA 95376 <br />PERMIT TO OPERATE - ItiS - MOBILE F<M)I> PREPARATION UMT(MFFV) <br />Record ID H PR0MM66 <br />VEHICLE LIC«4VF5876 <br />Valid From 01/01/2025 To 12/31/2025 <br />Mcvw^n »<cvm Ccrp <br />212 W W*y <br />Mo,*«L»nMcuM CA 95391 <br />RSNEE DAVIDSON IIC aOOJUW <br />4WW LARCH RO. STEA <br />Tracy CA 95334 <br />SAS JOAQUIN COUNTY FNVIRONMENTAI. HEALTH OEPARTMENT <br />IUX E. Horlhm Await .MKklw. CA - PMnr (W) 4MA43B <br />Jaiftl Kane. RXII^v. Oimfor <br />-V.*.' 0 J <br />G4M1 IMT ”■ <br />•OICY___)5cr I____3©c <br />KPTOMOMC <br />RNVMJ1O <br />___ A-fMM’ <br />PERMI IS TO OPERATE arc SOI TRANSFERABI.F <br />and mi) be St SPESDED or REVOKED Ur came <br />PERMIT!») Valid od> f«: CARBAJAL ARMANDO <br />DBA LOS PRIMOS TEX-MEX FOOD 92 (4VF5B76) <br />MKl <br />2S151 <br />SHOULD *** Of TM A»QVt OTSCIUMD »OUCW» M CAMCCLUO MfOAE <br />tk ixfwaiiow DATC rNtnro*. nonet m otimmo m <br />ACCOtDAHCi M1H TMf MM ICY rROVtW** <br />4CK l*A tU A^-Ol KIMMMO A_'O1<*4» <br />KANOALAFT. ALEJANDRO A MORENO MARIA <br />DBA LOS PRMOS TEX-MEX FOOD LLC <br />21 GRANADA WAY <br />_______________TRACY, CA 953F6-? 125 __________________________________________ <br />COVERAGES CERTIFICATE NUMBER REVISION NUMBER <br />TWO <3 TO CERTFY THAT T»< POlICKS C# aCVRANCE LISTED MlOW HA%T BEtN ISSUED TO HR IMU*UU NAMtD MOVE FOR T»< PCX ICY Pt«»OO <br />•.OCATtD NO^TK$1AND»MO ANY REQuMEKNT. TtRM OH CONDITION 0* ANY CONTRACT CM OTm(R DOCUNtNT NITm Rf5»fCT TO TiKJ <br />CERTFCATC MAY BE ISSUED OR MAY PERTAP. TX HSURANCE AJFORDED RY T< ACLIGES DCSCRAFO HtREK »3 SUBJECT TO ALL THE TERMS <br />LXCLUSiONS ANO CONOCiONS Cf SOCM POlCES WATS S'O.VN MAY HAVE MEN REDUCED 8* PAO ClAAH <br />gSISI! ~ — L-n <br />COMMA O«MUtM.MMUTV <br />___I CUNMMM lx. OCCUR <br />eSOZ/lOJB nuAvi^6/a' <br />G4MAA-AQOMCOAH <br />NUOUCTA. QOM^er NX1 <br />kr-OFZioH-MUiniTHi <br />____________ <br />c 1M1-281S ACOROX^XfrORATlON AR nflM. re.^ved. <br />TM ACORD n»m and to^o Me rpflatowd mart! o< ACORD <br />,_loCOA« <br />icuwtMAX <br />C4O ] •r-is’c*. 1 <br /><■*> IWWIM B <br />.V MOMt r —. <br />CinyvHiMluajJia’ <br />.-iSJrua. I ST <br />If. CMMAM tAtMnor;^ | <br />11 • oiau .rac’iM- 1 s <br />I OATt (WMWYVrn <br /> _________________| 10^23 <br />THIS CERHF1CATE IS ISSUED AS A MATTER OF ^FORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTVCATE HOLDER THU <br />CERTFICATE DOES NOT AFFIRMATTVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED SY THE POLICIES <br />BELOW THIS CERTIFICATE OF BMURANCE DOCS NOT CONSTITUTE A CONTRACT BETWEEN THE (SSUBiO WSURER4S), AUTHOR KEO <br />REPRESENTATIVE OR PRODUCER. AND TMC CERTIFICATE HOLDER____________________________________________________________________________________ <br />IMPORTANT: r IM C^tMcata MMm la aa ADDITIONAL INSURED. IM paMyflM) moal Mw ADDITIONAL INSURED provHI«M ar M andorwd <br />■ SUBROGATION IS WAWED, •ub^act t® IM Mom and coodAtac* af «M paRcy, cartala potciaa may taevlm an andar»ama«M A Hatamanl an <br />tMa cmWIcata data not coalac rtghla la (ha carttfteata MMer In Mw al tach ewdaf»ama<rt(»)____________________________________________________________ <br />MONICA ASIMY <br />SyLu,,. 209*30WF~ |a£.^ '______ <br />MONICA ASHBY VAHSTUftSYATFFARM COM <br />, . ______a.|muiam an paaam cov<A*aa__________ mijira a S’ata Fawn Oanarai toturanoa Coryary _____ <br />s <br />uaeafeAAiM <br />HCIHKl