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COMPLIANCE INFO_2021
EnvironmentalHealth
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1600 - Food Program
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PR0546548
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COMPLIANCE INFO_2021
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Entry Properties
Last modified
11/3/2021 11:57:54 AM
Creation date
3/25/2021 8:21:10 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
COMPLIANCE INFO
FileName_PostFix
2021
RECORD_ID
PR0546548
PE
1635
FACILITY_ID
FA0026397
FACILITY_NAME
TACOS EL CAMPESINO #14060Z2
STREET_NUMBER
620
Direction
S
STREET_NAME
SACRAMENTO
STREET_TYPE
ST
City
LODI
Zip
95240
APN
04532005
CURRENT_STATUS
01
SITE_LOCATION
620 S SACRAMENTO ST
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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EHD - Public
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I <br /> SAN .J O A Q U i N Environmental Health Department <br /> --C O U N T Y---- <br /> a,; Greotness grov:s here. <br /> COMMISSARY AGREEMENT <br /> Mobile Food Facility + Caterer <br /> Complete sections 9 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 , c Lic. Plate# 775 <br /> Owner/Operator Name <br /> Business Mailing Address ' ��"ZzetLle <br /> City State,�ZipQ�Bus. Ph.(Za� Z 1 7T�q6kIt. Ph. <br /> I, 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 pen (ties. <br /> Signature Ut V �p1�i(1 Date(IZ-- Z l <br /> 2. To be completed by COMMISSARY OWNER/OPERATOR <br /> Commissary Name V FA# <br /> Address 6,Z& S 4e) s+ Bus. Phone <br /> City Z-yRI , Zip gSZV Owner/Operator 6lr4u,jjt.,-o <br /> Check all appropriate services provided: <br /> wastewater disposal P-*3^-compartment sink M'-'Electrical hook-ups <br /> olid waste disposal Urfood preparation I$ Toilet and handwashing <br /> 111 Hot & Cold water for cleaning Store refrigerated food13/�`otable water <br /> wgiore dry food/supplies EV10"vernight parking Ltd vehicle wash <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 <br /> �immediately. <br /> Signature Date �— L <br /> 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. <br /> REHS Signature Date <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />
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