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WSW lev <br />I <br />Applicant's Name:Roderick tylerI 12/31/25 <br />j <br />House of ice creamDoing Business as: <br />I <br />equate number of approved electrical hook-ups ',i <br />Date: Commissary Owner/Manager Signature: <br /> ' <br />I <br />I <br />Approved utensil washing sink <br />Other services: <br />Fax: 510. 981.5305 <br />handled for use in mobile food facility <br />with offsite preparation <br />NOTE: Please notify this department within five (5) working days if the applicant stops using your facility <br />Duration of <br /> Agreement: <br />fe and sanitary wastewater disposal <br />nitary delivery of potable water <br />■nitary disposal of rubbish and garbage <br />^^ZHpt and Cold water for vehicle cleaning <br />^proved food preparation area <br />Signature of County REHS: Date: <br />2180 Milvia Street, 2nd Floor. Berkeley. CA 94704 Tel: 510. 981 5310 TDD: 510.981.6903 <br />Q-mail: envheaHh@berkGleYca.gov <br />Zip Code: <br />9524C <br />•7 REHS #: <br /> <br />Commissary Name: <br /> ________Commissary Azteca <br />Address: , ,620 s sacramento st <br />Business Phone:2092248334 <br />Name of Commissary Owner/Manager: <br />Aleiandrg---------------------please check all appropriate services that are provided: <br />N^F approved equipment <br />^TApproved food storage facilities <br />Mptrftain service records <br />Approved janitorial sink <br />Facilities to repair vehicles <br />prernight vehicle storage <br />Approved toilet and hand washing facilities <br />Health, Housing, and Community Services Depart <br />Environmental Health Division c0|V|M|SSARY VERIFICATION FORM <br />I hereby state that the information I have provided is current, true and correct to the best of my knowledge and <br />meets the California Health and Safety Code requirements. I will Inform the City of Berkeley Division of <br />Environmental Health within five (5) days if the applicant stops utilizing my facility. <br />ENVIRONMENTAL HEALTH DIVISION: If the commissary is outside of the City of Berkeley, the local <br />environmental health jurisdiction shall verify current commissary health permit by signing below. Commissary <br />is in 9^ Tcj -z.,.: County. The facility above meets commissary requirements (CalCode, Chapter 10, <br />Section 1142T1, 114245.1, 114294, 114326-114327). The above checked services are available at the <br />proposed commissary. <br />REHS Printed Name: ‘ - _______ REHS #: Wil <br />Phone/email: - <br />City: <br />Lodi <br />County Location: <br />San Joaquin________