Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> ,Fz•:r s rTs'k"r`1r�2' tea,: ,�F'7 r`�.t s ,...,F t ., y z. vn 3 y�^-Y- ,-r-�s x. <br /> Vehicle Name (DBA)c 7)Lk f r,:2,C.' <br /> Address for Vehicle: I� 0 J G c� <br /> Street Address city <br /> 1) License Plate#: � Q 2 '71 se 4) Year: C C' <br /> 2) Vehicle Vin#: T�((�5 �f bV � Make/Model: -1 .) <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWN R NEORMA�ION '`� ," �`�,` .� `£�`""��- 9�5.,� �,��'..�'`w��� ' ��,�' ' •� .,�" <br /> Name: <br /> Address of Ow er: Sc, <br /> Street AdIdress 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 /> V"q-wv I Iq bo Z <br /> Si nature otVehicle Operator Date <br /> OMMISSARt. ORNJ�e ATION _�, .. <br /> <.. <br /> Business Name: C G p E C re F <br /> Owner Name: S'A n,igy� S/' S <br /> Site Address: Q C—IV TC— k\) S?-o 70/x/ C► 5a\ <br /> Street Address city <br /> Phone: -T) o ---? --� <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 /> ❑ Liquid&solid waste disposal Utensil washing sink '��Store frozen food `� Vehicle wash facilities <br /> (2 or]compartments) <br /> ❑Preparation of food Hot&cold water for cleaning Toilet&hand washing -15 Store refrigerated food <br /> ❑Store dry food/supplies ❑ Provide potable water \❑Overnight parking Adequate electrical outlets <br /> 61'— l�— `D,-\'\.S588 E.CARPENTER RD. <br /> Signature of Commiffsary Owner/Operator Date STOCKTON,CA 95215 <br /> s�,ay.w -� �,.-+-s� awes <br /> Oji, 7ki . PARTMENT � k k, 't g� �. N . <br /> 4, t.. ( A�4v c?. �.n'.'Z .3 <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 /> 7/18/2008 <br />