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): itlik)77-677 Tos A2 6-------x ( it Aso s.--:4' , 9 / .5 77. <br />Address for Vehicle: 2z1 ? 66 oz , ( 7)66: ,Alvc 5 -recA/cA1f C19 <br />Address City Street Address <br />License Plate #: S4' 69 go q 4) Year: / ? ?e <br />Vehicle Vin #: 5) Make/Model: F-A) /-/ r <br />State Decal #: 6) Color: if (Tel- <br />VEHICLE OWNER INFORMATION <br />Name: Vi g 6 /Aim 5iiik/1 11 Cz_- iz i c,s <br />Address of Owner: 2 q ? ccoi._/.066 4 6/ - 5 -r-1) 6.: K nvu Cd. 952/ ,--- <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 />1 // 2 3 6 <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: (ii N ( 0 it) Cif 7-Ep( ( ilk 7 -4 ti . . k <br />Owner Name: <br />Site Address: / '7 ( 7 s . a Iv / 0 ,01 ) sr . 5 7-0 c -1---6)q, <br /> <br />2 o? , j_. r\ Street Address City <br />Phone: ( ) 7 .-- zif/ L <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 />r- Utensil washing sink Liquid & solid waste disposal <br /> <br /> agiore frozen food 3/Vehicle wash facilities (2 or 3 comparimer.L5) <br />aration of food <br /> Store ry <br />fp 114ot & cold water for cleaning rq-<oet & hand washing KStore refrigerated food <br />1.--r3rovide potable water 71-fvernight parking equate electrical outlets <br />m <br />d food/supplies <br />• /-3 -6 ---• - 'V I* , / / <br />Signature of Commissary Owner/Operator Date <br />:HEALTH DEPARTMENT,L ,'' <br />If the commissarylfood establishment is outside San Joaquin County, the local health jurisdiction must verify <br />current health permit by signing below. Commisseryllood establishment is in <br />County. <br />Signature of County RENS Date <br />EHD 16-017 5 of 6 iv1FPU APPLICATION <br />7/18/2008