Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: V6 5, 14 G,'NS7, STk-A) <br /> Street Address City <br /> 1) License Plate#: 4) Year: 12 QZ <br /> 2) Vehicle Vin #: 5) Make/Model: ZNTX,S <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: "` <br /> Address of Owner: 22 qC 5 /� ,� n/j �� 57-OG 104J Q C)E <br /> Street Address City <br /> 110ii ... 4_ out <br /> of and <br /> Sh..11 rt to 4L... .. .. L 1, --4- n ^L. <br /> I iiC IiiV Ui1C IUUU iGl.i lily J{{GII Vi.i CI GLC VUL VI a l.Uli lliliJJaly aiiU JISG:i reportto Li{C 'vvii7iiil,.Zaiy OL i�QZL Vlil.� ea:..11 <br /> operating day for cleaning and servicing (CalCode sections 114295 & 114297). 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 /> i nature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: a/If(O N C fi TE /)G <br /> Owner Name: S/f Z-(//J bl 0 k IR <br /> Site Address: Q S'( S1T C k7-04,J C O <br /> 9 Street Address City <br /> Phone: )/ <br /> I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked q <br /> below::- <br /> � <br /> Liquid&solid waste disposal U Utensil washing sink tore frozen food EJ-Vehicle wash facilities <br /> or 3 compartments) <br /> reparation of food Hot&cold water for cleaning 0 T ilet&hand washing ore refrigerated food <br /> Store food/supplies vide potable water [a�erni ht parkin dequate electrical outlets <br /> �9 0 <br /> Signature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />