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): L__,--,_ bki Acy, t*,e xv- 400 c <br />Address for Vehicle: /5 d / 6 5 Ac e-As-vt_Q--0-0-, S\ • L ,.-v , c ,k /. s.-7 (c) <br />License <br />Vehicle <br />State <br /> <br />Street Address City <br />, <br /> <br />. ,, <br />Plate #: '5 a I co I v W 4) Year: t <br />,iii---12- Vin #: / 6 Dole;)_1?-6v3,,, 5) Make/Model: <br />Decal #: 6) Color: &. A de- <br />VEHICLE OWNER INFORMATION <br />Name: <br />Address of Owner: <br />The mobile food <br />operating day for <br />discontinued, the <br />office may re I <br />Street Address City <br />facility shall operate out of a commissary and shall report to the commissary at least once each <br />cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br />permit holder must notify this office to make the necessary changes. Failure to notify this <br />i per.- it revocation and penalties. <br />Signature o i 4; k e Operator Date <br />COMMISSARY INFORMATION <br />Business Name: (01ff ati, k Z . 1-4 .//k <br />Owner Name: 6i( /4) /.1. id cA /..",'. 87-2-- <br />Site Address: //0/ g; -C-Greif-f eAZ S./- ‘a / 6/ 9) <br />Street Address City <br />Phone: (h)) 7 3 ci,-- ,,,,r — 23 <br />I, the commissary <br />commissary as checked <br />ryr Liquid & solid waste <br />Ti Preparation of food <br /> Store dry food/supplies <br />' <br />An' <br />owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />below: <br />1 I Utensil washing sink disposal ri Store frozen food F-- Vehicle wash facilities (2 or 3 compartments) <br />y- Hot & cold water for cleaning fToiIet & hand washing I 1 Store refrigerated food <br />[Provide potable water NTOyernight parking (X. Adequate electrical outlets <br />. / A‘P"—A0/ <br />-r1PCperator Signature of Commissary Date <br />HEALTH DEPARTME / <br />If the commissary/food <br />current health permit <br />County. <br />establishment is outside San Joaquin County, the local health jurisdiction must verify <br />by signing below. Commissary/food establishment is in <br />Signature of County RENS Date <br />EHD 16-017 <br /> 5 of 6 <br />MFPU APPLICATION <br />7/18/2008