Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all Information requested. An Incomplete application may delay approval. <br /> E,I' <br /> Wmdc N _dKWAT'16Nr"�, <br /> Vehicle Name (DBA): /L /f ////(f/ d <br /> Address for Vehicle: 3 03 /or# L5 41 r. <br /> P/7T <br /> Street Address city <br /> 1) License Plate#: Q(97ozE.l 4) Year: ct 9 <br /> 2) Vehicle Vin#: 5) Make/Model: Ch'�51-1 <br /> 3) State Decal #: 6) Color: &M Z 7—E <br /> Name: Z- <br /> Address of Owner:3 C)3 e5. 16777' S7—. P61 TTS,61YR6 C� 7 41 6-6-6-- <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 (CaiCode sections.114295 & 114297). If the-use of the commissary Is <br /> discontl ued the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office y result In permit revocation and penalties. <br /> ;4nature of Vehicle Operator Date <br /> COMMISSARY'WF6kmXTIOW <br /> Business Name: (fEN7-ef& <br /> Owner Name: C519L v/�do of 77;e M(5 <br /> Site Address: 1,beVleW L5_762Ct)ZW ClY 9:�04 <br /> -.20 /7/7 i;� �ST—,Address city <br /> Phone: ( Z '?ff —'s /� <br /> 1,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> Eatquld&solid waste disposal ED"Utensil washing sink EDgit`ore frozen food CaVekicle wash facilities <br /> (2 or 3 compartments) <br /> D- <br /> ErPreparation of food El"Hot&cold water for cleaning [�-foilet&hand washing Store refrigerated food <br /> B/Store food/supplies 2Provide potable water ED-15v'smight parking Adequate electrical outlets <br /> Si nature of Commissary Owner/Operator Date <br /> WEALTH DEPARTMENT''. . . , "*� ,,, .1"�� 7 <br /> P <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 REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION- <br /> 7/1612006 <br />