Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An inccampl;ete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DSA): �. <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: e V�?03�Z 6 4) Year: / 9, <br /> 2) Vehicle Vin#: ICEG 1�,a3a lS�1433aa`f 05) Makei`Model: CGI Qy V <br /> 3) State Decal #: 6) Color: <br /> '1filLE.O�M1fNEFt-�t FOlafillATiC3Ef . :a <br /> Name: ��, (T�s 2v r 715- 7018 <br /> Address of Owner: UJ s4, S C33 <br /> Street Address city <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 114296 & 114297). If the use of the commissary is <br /> discontinued, the permit holder roust notify this office to make the necessary changes. Failure to notitry this <br /> office may result in permit revocations and penalties. <br /> -To�k <br /> Signature of Vehicle O eeatdr Date <br /> cOlf MISSARY INFCT'RMATi® <br /> Business Name: 1 ' <br /> Owner Name: / / z TED, <br /> Srte i-iU(StCJJ. — <br /> Street Address "y <br /> Phone: (2 <br /> 1,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> tensil washing sink Store frozen food e idle wash facilities <br /> Liquid&solid waste disposal (2 or 3 compartments) <br /> reparation of foodof&cold water for cleaningoI et&hand washing Store refrigerated food <br /> �to�ry food/supplies rovide potable water 0-6v", ht parking �,deg4ate electrical outlets <br /> /aa /« <br /> Signature of Commissary Owner/Operator Date <br /> HtAI H ,AFARTMENT. <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Cosi missaryffood establishment is in <br /> County. <br /> Sinature of County RENS Date <br /> EHD 16-017 5 of 6 MFPU APPLICA i ION <br /> 71118/2008 <br />