COMPLIANCE INFO_2019 - Laserfiche WebLink

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VERIFICATION OF VEHICLE COMMISSARY Please provide all Information requested. An incomplete application may delay approval. W 0 Vehicle Name(DBA): C,,' ry-I Address for Vehicle: Street Address city- 1) License Plate#: 4) Year: U 19 2) Vehicle Vin#. (-b-Tr\v8, 6-?(-i 7F--/0Lj0 ) Make/Model: (.1,tq tyl 3) State Decal-#: N 6) Color: f N Name: yo Address of Owner: o r street Address city The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing (CalCode sections 114295& 114297). If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office may result in permit revocation and penalties. P�'I I L') i'), I Z;-2 5/, r.-' I� — Si nature of Vehicle Operator Date WxJ ENO I INSISTED, -W Business Name: Owner Name: 7 Site Address C-7 gV-7- ic� 7'6 K 7-o jL Street Address city Phone: u,) V\7- 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my commissary as chocked below: ❑ Liquid&solid waste disposal ❑ Utensil washing sink Vehicle wash facilities Compartments) or 3 COMp2ments) Store frozen food ❑Preparation of food ❑Hot&cold water for cleaning ❑Toilet&hand washing Store refrigerated food El Store dry food/suppies ❑Provide potable water �Overnight parking U Adequate electrical outlets PJCT�IN GO TCE CRT]AMI CARPENTER RD. Signature of Commis!kary Owner/Operator Date E U C.A .95215 NN't If the commissary/food establishment is outside San Joaquin County,the local health-jurisdiction must verify current health permit by signing below. Commissary/food establishment is In County. Signature of County RE HS Date F=HD 16-017 5 of 6 MFPU APPLICATION 7/181200B