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COMPLIANCE INFO
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EHD Program Facility Records by Street Name
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SACRAMENTO
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1301
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1600 - Food Program
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PR0548249
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COMPLIANCE INFO
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Entry Properties
Last modified
6/7/2023 3:57:10 PM
Creation date
6/7/2023 3:51:55 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
1600 - Food Program
File Section
COMPLIANCE INFO
RECORD_ID
PR0548249
PE
1635
FACILITY_ID
FA0027531
FACILITY_NAME
TACO FELIZ #8M11300
STREET_NUMBER
1301
Direction
S
STREET_NAME
SACRAMENTO
STREET_TYPE
ST
City
LODI
Zip
95240
APN
04529028
CURRENT_STATUS
01
SITE_LOCATION
1301 S SACRAMENTO ST
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\ymoreno
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EHD - Public
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SAN JOAQUIN <br />COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />COMMISSARY AGREEMENT <br />Mobile Food Facility. Caterer <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 />Business Name --77-3C0 -F--e /12 Lic. Plate # S.-g1 / /---3cr, <br />Owner/Operator Name Pa/77/r0 OCA0.- • <br />Business Mailing Address /5 --at. (3y /9-(/(' <br />c_v t„c ck/i State Ch-Zip?527(70 Bus. Ph. Alt. Ph. 0.2 q ri002/3q • <br />I, f'sal,(,//?() 0-6,6t7 , 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 permi,t-holder must notify the EHD. Failure to notify this office may result in permit <br />revoca,r_anl d-penattie . <br />Signature / Date <br /> <br />2. To be completed by COMMISSARY OWNER/OPERATOR <br />Commissary NameC—oili-q/ V6,',- I . -.e.i./7/1 FA# <br />Address L7d/ C -Qi,- 41/2 (--/-7' i 1- Bus. Phone (?z/ 1,7y,4-7 .r <br />City :_/ zik Zip S...-iV.4 Owner/Operator /, r‘./le/71.) <br />Check all appropriate services provided: <br />0 Wastewater disposal 0 3-compartment sink 1:3 Electrical hook-ups <br />Solid waste disposal 0 Food preparation El Toilet and handwashing <br />D Hot & Cold water for cleaning 0 Store refrigerated food Et Potable water <br />Store dry food/supplies p Overnight parking 0 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 immediately. <br />Signature Date — --7 <br /> <br />3. To be completed by th 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 I T 209 468-3420 I F 209 464-0138 I www.sjgov.org/ehd
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