Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): . 1/ ci 5 'on t ) <br />Address for Vehicle: 0 S ., rx CYCV -11 .//./ 0 S/ 75:2110 /c., di <br />Street Address City <br />License Plate #: 81.,c ( 73 11-9 4) Year: ( -7 ;7 <br />Vehicle Vin #: ipt 3 g--??(;„ Co3c,,, 5) Make/Model: <br />State Decal #: 6) Color: 67 c;.67,41 <br />VEHICLE OWNER INFORMATION <br />Name: 54 1 va du, vo ye, I c,. <br />Address of Owner: C( Lr. Lij 0 0 c:( you) 5 I- 1 0 .-.b 7S 2. 41 0 <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 />ScA ki CkdOi V a 3re_ (c- R <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: 6o p4iM i 55-et r / IV Z-t-e-e-t.._ <br />Owner Name: ni 43,4 v-/ ej PO -*-; /4'6(.. <br />Site Address: 6 ,),e) 5 s,c1,4 .1e, s '- 416 2 96/ <br />Street Address City <br />Phone: (),e't ) 11 5 57 <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 />1-- Utensil washing sink uid & solid waste disposal FT-Se frozen food M \---/:1-licle wash facilities (2 or 3 compartments) <br />_. <br /> Preparation of food Hot & cold water for cleaning P 1---r;1; & hand washing more refrigerated food <br />1---‹-ore dry food/supplies FK;rovide potable water F%-v-ernight parking I-X-c-leguate electrical outlets <br />Signature of Commissary Owner/Operator Date <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 RENS Date <br />EHD 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008