Laserfiche WebLink
Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): A a jC' C� <br /> Address for Vehicle: lo 3Q,4-' G►.o1.j' 1 q1 rz1V5 La <br /> Street Address City <br /> 1) License Plate#: ,3 1 g(-f hi 4) Year: %f <br /> 2) Vehicle Vin #: 6'7'2N&1'6W6FS2te7P Make/Model: 67 PIC <br /> 3) State Decal#: 6) Color: <br /> 'v'Etie'vL.E vcINH—ER eN. `it1"v"i. <br /> Name: �P AL�j j R K MJ R <br /> Address of Owner: 03.2,6 65PLS= 41,767CIVSN _ 7JOGk70W z-- 6 5-2'o <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 & 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 /> -T/144-VtI? K a U 0 Bali - /1,5- <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: C f. � 0 <br /> Owner Name: -7-/-J/'A1n,7 F c �' s' j o <br /> Site Address: �S(';'' L=' C -1 -;p(=. jV-77 - S T' Cr ''aN -- <br /> Street Address city <br /> Phone: (SIFT) j.� t,,q, <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 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 ''Q Adequate electrical outlets <br /> _ t'K'N GO TCR CREAM <br /> Signature of Commissary Owner/Operator Date <br /> O�4,CA 95215 <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 />