Laserfiche WebLink
4 <br /> VERIPCATION OF VEHICLE CrOMMISSARY <br /> Please provide all imo-rnation requested. an incomWete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: 70 <br /> Str at Address City <br /> 11 License Plate#: C 4.) Year-. -------- <br /> 2) Vehicle Vin 4: <br /> s 3 ake/Model: -- <br /> 3) State ©eCBi r: - --_.- Jl Color: <br /> 7-- - -- -- —W— ------ <br /> VEHICLE OWNER INFORMATION <br /> - - --- ----- —------------ <br /> Name: <br /> Address of Owner: - <br /> ---- - Cr ''- - m C--�, ------- <br /> Street ,dress City -1 - <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 (Ca{Code sections 114295 & 1142a7), 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 in permit revocation and penalties. <br /> l <br /> Signature of Vehicle Operator <br /> --- -- -- ere — -- <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> -Lex" - P� ----- ------ <br /> Ovrner Name <br /> Site Address_ <br /> Street Address City <br /> Phone: (Z01 2 '�-�� -----. —--------- — -- -- -----. _ <br /> I, the commissary owner, Can and vrill Lir^;ide the ^scessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> I <br /> 1 I^UfC L SC!Id waste disposalL—' et�S;i vV85F'i Cl S rK. — <br /> Store <br /> . S^toare , fcC 1- wash Si <br /> 2;r 3 conparr-w.`z <br /> , PrAear ti n Cr food' C T(�r -,ar,d v�s ira f3C.i li`:o <br /> a <br /> dr! loord.Ssuc!jnc <br /> l <br /> i <br /> Siam'° re of Commissar,] Or:;:eri��pera{or ©ate i <br /> HEALTH DEPARTMENT r <br /> If the commissary/food establishment is outside San Joaquin County, the local health iurisd{ction mast ve-rir'V I <br /> current health permit by signing belo °.r. ,oMMmissary!food establishment is !r, —_-- --^_—_ <br /> County. i <br /> Signature ^f County RFHSDate <br /> t <br /> GHr 16-0'17 <br /> 7i rp%26G <br />