Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all Information requested. An incomplete application may delay.approval. <br /> ^�/�-`�y}'aY a -��.'.�-�.%-..�""=�'"r �5=- -'�'�"s�e�3� ,u-�. r���,t.y �m�•���-...s�,r:``�'"�_.Ys �' `ri �- . <br /> �Ei�1�:E��NFORI�I[�A�Q;[�r�a..+ �, t � T��.r �� r _1'"'z'.�" �_�x�..✓�_°_`i .-..��•.� _ <br /> Vehicle Name(DBA): S 1C e Cid Ell <br /> Address for Vehicle:. U ; 1/4'14AA. L C it <br /> Street Address city- <br /> 1) License Plate A. `J /J5 0 9 69 4) Year: f -( Cl "! <br /> 2) Vehicle Vin# 2 FT 4�q> 5R f IS'A5) Make/Model: %=0 R <br /> 3) State Decal-#: C Pr 6) Color: <br /> VE,HCCLII0-RNLA.�ON �'.�i_2j`" _ <br /> Name: <br /> Address of Owner: j o ;, i l-v 7v�- krk 41q lF(4 C fit- �- <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 114295& t14297). 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 /> ___� AMf /� S' l )vQ__ l l <br /> Si nature of Vehicle Operator Date <br /> y-•,m,a aH.G.�-:.:ctY].aas- '�T, ':n" r 10 <br /> -s,na f - 'a'.s[. f.c ,r,r-e=F�'-rmy'Wifi�v"-"3-- .ir, >+.r-:.s- �.C,r-.y.-,.� �,^_.r•_ <br /> -n <br /> •-__•-..__ .._ _.: ..,-.rrr,.n ._;�..,; '?rY`�'G "+.�b:�J�t's. r�-.�c a�.rc�.t •-.__._.��-d.°4`;Y!-.:..�...C: <br /> Business Name: 1 c c CV c- <br /> Owner Name: S' ;rrr d�• " rV <br /> Site Address: 3 S F C' 12 vl)lTL A D s-- , <br /> Street Address city <br /> Phone:.(a�,6: ) c'j <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 /> ❑ Liquid&solid waste disposal ❑ utensil washing sink Store frozen food -0 Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑Preparation of food ❑Hot&cold water for cleaning Toilet&hand washing `" Store refrigerated food <br /> ❑Store dry food/supplies ❑Provide potable water Overnight parking 0 Adequate electrical outlets <br /> signature of Commissary Owner/O erator Date '1 "�!' .A 95215 <br /> HFTH DEfrJ�t7;lp[EN�`�=� �� ��-c'Y�-•`'-r-'�L_`�.��. . � �� __:, � � _ >� _y r_.x�,. a =as._ ,t .�,.Y�_H.y'._�as_ ;� . <br /> If the commissarylfood 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 RE HS Date <br /> EHD 16-017 5 of 6 _ MFPU APPLICATION <br /> 711812008 <br />