Laserfiche WebLink
VERIFICATION OF VEHICLE COtMiSSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): <br />Address for Vehicle: --9--4-- -4 .\\A-..!...-• (..,3 . 3T-\ cits,,, <br />License Plate <br />Vehicle Vin <br />State Decal <br />\ Street Address City <br />--)..-", #: 4) Year: r-- ...- ... <br />#: L-iScA&(3\ .D,37‘.-(13:/,) Make/Model: <br />#: og."--9-00 6) Color: Li...*eie" ( N-N1/4-klic.- <br />VEHICLE OWNER INFORMATION <br />Name: RD16\,r- p-,---Nk\eit\,,-(,..,, ( \-z k..kio\--Vti <br />Address of Owner: cv-k u3 \c:\v- k_ J.,\ v -v--\A---.. kt-‘(.03e.._ CIN„ ci\s--gA k <br />1 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 />L--\\ - - - <br />Signature of Vehicle Opei-ator Date <br />COMMISSARY INFORMATION <br />Business Name:"-----\--cc:_), `:L.ALL---)C,:1-4.0 , <br />Owner Name: <br />Site Address:Cr\-ker pr `‘,, c--)V, C <br />t <br />—cf--c--=•.,.\ <br />--1 - )‘ Street Addres1 City <br />Phone: (d,c,c\ )),`"-,. <br />, <br />I, the commissary <br />commissary as checked <br />Faciuid & solid waste <br />1 <br /> Preparation of food <br />[*tore dry food/suppli-s <br />' 7 <br />owner, <br />disposal <br />can and will provide the necessary facilities for the above mentioned vehicle at my <br />below: <br />Ti Utensil washing sink ri Store frozen food 1----Crehicle wash facilities (2 or 3 compartments) <br />g-FfiSt & cold water for cleaning H.-TO-Het & hand washing Li Store refrigerated food <br />L--19r6vide potable water vernight parking E-A-dequate electrical outlets <br />Signature of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <br />If the commissary/food establishment <br />current health permit by <br />County. <br />is outside San Joaquin County, the local health jurisdiction must verify <br />signing below. Commissary/food establishment is in <br />Signature of County REHS Date <br />EHD 16-017 5 of 6 <br />MFPU APPLICATION 7/18/2008