Laserfiche WebLink
?I5i ' <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): —� tS _ 71k <br /> Address for Vehicle: <br /> Street Address r� � City <br /> 1) License Plate#: 4) Year: (� - <br /> 2) Vehicle Vin #: 3 5) Make/Model: { <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> f <br /> Name: � th�a <br /> Address of Owner: ?_D A-1,Q 1 <br /> Street Address Clty <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 (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. 4 1 If <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION. <br /> Business Name: ' ' �1�( �{ CYI I'1 �G D,S(;r1'IC1✓ i t <br /> Owner Name: Yi Own <br /> Site Address: S.- t I/ WM <br /> Street Address city <br /> Phone: ( 24 4 — 1 <br /> I,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> Liquid&solid waste disposal Utensil washing sink Store frozen food Vehicle was <br /> i2 0 3 compartments) h facilities <br /> �/P <br /> reparation of food of&cold water for cleaning 7vern <br /> &hand washin­, Store refrig rated foo <br /> Store dry food/supplies rovide potable water ight parking Q�j qu tJ T A;Q f tZtlets <br /> z- 6 S. AIRPORT W' %Y <br /> 1)4 <br /> I �� STOCKTON, CA <br /> Signature of CON missary Owner/Operator Date(( (209)466 9000 <br /> HEALTH DEPARTMENT m <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 />