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Roderick tyler J2/31/25 <br />House of ice cream <br />Date: Commissary Owner/Manager Signature: <br />^Ll <br />P^OSHlpW <br />Health, Housing, and Community Services Department <br />Environmental Health Division <br />Duration of <br />Agreement: <br /> <br />Zip Code:9524[ <br />COMMISSARY VERIFICATION FORM <br />“Commissary” means a food establishment in which food, containers, equipment, or supplies are <br />handled for use in mobile food facility, mobile food preparation unit, food carts andJernporary_fQQ2-l^------- <br />with offsite preparation <br />NOTE: Please notify this department within five (5) working days if the applicant stops using your facility <br />Applicant’s Name: <br />: I <br />t 5 <br />Doing Business as: <br />Commissary Name: <br />--------------Commissary Azteca <br />Address: <br />620 s Sacramento st <br />Business Phone: <br />2092248334 <br />Name of Commissary Owner/Manager: <br />Alejandro <br />rc. pg, r <br />approved equipment <br />Approved food storage facilities <br />r^^MaPTtain service records <br />Approved janitorial sink <br />jX facilities to repair vehicles <br />O' Overnight vehicle storage <br />jX Approved toilet and hand washing facilities <br />Please check all appropriate services that are provided: <br />fe and sanitary wastewater disposal ' ' <br />itary delivery of potable water <br />itary disposal of rubbish and garbage <br />4 and Cold water for vehicle cleaning <br />|jjX^APProved food preparation area <br />XX'Asfequate number of approved electrical hook-ups <br />z Approved utensil washing sink <br />Other services: <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 County. The facility above meets commissary requirements (CalCode, Chapter 10, <br />Section 114211^114245.1, 114294, 114326-114327). The above checked services are available at the <br />proposed commissary. <br />REHS Printed Name:Phone/email: J <br />REHS #: <br /> Signature of County REHS: ------------------------Date' —'X <br />2180 Milvia Street, 2^ Floor. Berkeley, CA 94704 Tel: 510. 981.5310 TDD: 510.981.6903 Fax: 510. 981.5305 <br />E-mail: envhealth@berkeleyca gov <br />City:i h <br />Lodi <br />County Location: <br />San Joaquin_______