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Environmental Health Department <br />ki-1 r <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 />2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Vehicle wash <br />Date <br />3. To be completed by the ENV HEALTH jurisdiction outside of San Joaquin Co. <br />REHS Signature <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjgov.org/ehd <br /> Electrical hook-ups <br />H 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 />Overnight parking <br />____, 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 />Signature <br />SAN JOAQUIN <br />COUNTY-- <br />Greatness grows here. <br />FA#J^______________ <br />Bus. Phone 925-75Q-4060____________ <br />Qwner/QperatorMichael Tango Ma^keting^gr15'097 <br />Commissary Name Promenade Shops at Orchard Valley <br />Address 1422 Grove Ave_______________ <br />City Manteca ^ip 95337 <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 />I Michael Tango <br />Bus. Ph.256-404-1415 <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 />______________Date 12/22/2025______________ <br />Business Name Kenston Farms DBA Wedge Hollow Farms (Ad Partner) [_jc p|a|e # IN 3790162 <br />Owner/Operator Name Sarah Preston (Admin/Authorized Agent); Nicholas Pitts (Operator) <br />Business Mailing Address 1053 Commerce Blvd <br />City Pelham StateAL Zip35124 <br />I, Sarah Pieston 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 />S i g n at u re PaiOM Date 12/19/2025