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COMPLIANCE INFO_2018-2018
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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CALIFORNIA
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1600 - Food Program
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PR0541215
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COMPLIANCE INFO_2018-2018
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Entry Properties
Last modified
8/26/2020 8:47:28 AM
Creation date
8/26/2020 8:46:46 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
COMPLIANCE INFO
FileName_PostFix
2018-2018
RECORD_ID
PR0541215
PE
1635
FACILITY_ID
FA0022950
FACILITY_NAME
SELF MADE SEAFOOD #4NM5120
STREET_NUMBER
730
Direction
S
STREET_NAME
CALIFORNIA
STREET_TYPE
ST
City
STOCKTON
Zip
95203
APN
14723003
CURRENT_STATUS
02
SITE_LOCATION
730 S CALIFORNIA ST
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
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JCastaneda
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EHD - Public
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t <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): "i L-6TN 6,D e - "(i '- <br />Address for Vehicle: .24) <br />& 69M�E yy �c- <br />Street Address ' City <br />•i} License Piate #: J'-7 � 1 /0 7 2 (J / 4} Year: /i�(� <br />2) Vehicle Vin #: 1146VI03„)//ydf(j•33, ) Make/Model: Cf/�yi2/)P 36 <br />3) State Decal #: 6) Color: y3iuzF <br />VEHICLE OWNER INFORMATION <br />Name: � l wuE i 17 <br />,Address of Owner:,2,)4v, <br />Street Address City <br />The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br />operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br />discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br />office may result <br />resulltyiin�permit revocation and penalties. <br />a2 0 j D/� <br />' !G FyFQ� '?/ <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: OALL 1 tG67 <br />Owner Name: <br />Site Address: 24C S..- j yJ <br />AAJ <br />Street Address City <br />Phone: ( (j�,) ,-qk <br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />Liquid & solid waste disposal ❑ Utensil washing sink <br />Doors frozen food EJ Vehicle wash facilities <br />(2 or 3 compartments) <br />paration of food [Hot & cold water for cleaning �oilet &hand washing ,�StprarefGer""ipfe�!!d'fd�o/dt-'TIA l ATE <br />Vs"t'ore <br />dry food/supplies 5-1�rovide potable water E3Xernight parking SL, 12 LcYake?lIS; 7rcf KePtS <br />_ 2441, S. AIRPORT VVA <br />/l (° , ern -- STOCKTON, CA 9520 <br />Signature of Commis a Owner/Operator Date r(J {� (209) R66 900C) <br />HEALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />current health.permit by signing below. Commissary/food establishment is in <br />County. <br />Signature of County REHS Date <br />EHD 16-017 5 of6 MFPU APPLICATION <br />7/18/2008 <br />NNG <br />RACE <br />
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