Laserfiche WebLink
VERIFIWTION OF VEHICLE COAMISSARY <br />Please provide all MIP6rmation requested. An incomplete apillition may delay approval. <br />VEHICLE INFORMATION ....- <br />Vehicle Name (DBA): NNb '5 e N (R.O P6 TE a <br />Address for Vehicle: 92_5 iv\a_fp E_\2„S)... AVE • PATI-ERSON A G153e3 <br /> <br />Street Address City <br />Plate #: \--t NI 59 21- 4) Year: License I <br />Vehicle Vin #: ir-c1(3Qiia.k,C53:1100q5) Make/Model: V-AB\1\1 010 ' <br />Decal #: 6) Color: S ti—VEIZ State C iIN _._ _ <br />VEHICLE OWNER INFORMATION <br />Name: LS Av_milti\i00 PAAJAR-Ei <br />Address of Owner: LA2.5 M / I\LE. PA-TTERSONI , CA 616.36.& <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 res It in permit revocation and penalties. - <br />Vehicle 0. -rato, Da t.2 Catering S. e I ort Services — Sig_nature of <br />COMMISSARY INFORMATION <br />145 S. i oy Road . . <br />' A ° 380 Business Name: 67,.17-":_-,e_f7 /1/_5 ) ur ./. rr <br />Owner Name: <br />Site Address: / if C S- ke I (Le) t? a i %./ V I 4.) C se-- (%.* A 9 <br />Street Address City <br />Phone: (2,1. ) 63 (--1 - z e)es 0 <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 />Utensil washing sink <br />ET/Liquid & solid waste disposal /tore frozen food ErVehicle wash facilities <br />(2 or 3 compartments) <br />OPreparation of food 211'--lot & cold water for cleaning 71/Toilet & hand washing ,Store refrigerated food <br />OStore dry food's polies VProvide potable water gOvernight parking ,F7 Adequate electrical outlets <br />it-----: /3 - /C -2- <br />Si.griature of Commissary Owner/Operator Date <br />r <br />HEALTH DEPARTMENT _ _..• <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />below. Commissary/food establishment is in current health permit by signing <br />County. <br />Signature of County RENS Date <br />MFPU APPLICATION <br />EHD 16-017 5 of 6