Laserfiche WebLink
pan, 12018 8:18AM No. 2811 P. 2 <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An Incomplete application may delay approval. <br /> V ,TION.,' <br /> Vehicle Name(DBA): L]P <br /> Address for Vehicle: q 5 'j . i k (-6 q rwlocy- !`) 5 3 <br /> Street Address City <br /> 1) license Plate#r:: C V -+U( o1-1- 4) Year: _ CU O <br /> 2) Vehicle Vin#: 7, f -49—L 3,�HA35 Make/Model: &n <br /> 3) State Decal* C P7 6) Color: �1 rA K- <br /> r <br /> Name: <br /> Address of Owner: 6Ll V L#1 <br /> Street Address ci <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 114285&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 /> offi ay result In permit revocation and penalties. <br /> SI natun,of Vehicle Operator Date <br /> 'CQ MI'aSr4RY INFQFRMATION Y . :,, <br /> Business Name: 1.r; S. Ki:'(' <br /> Owner Name: I)rmk. CA g5::i8i/ <br /> Site Address: <br /> Street Address city <br /> Phone:(ZOy') C. 3(%- ,-2 i)p0 <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 /> Uquid&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 Store refrigerated food <br /> ® <br /> Signature <br /> dry food/supplies ©Provide potable water H Overnight parking Adequate electrical outlets <br /> t 7 <br /> gnature of Commisse Owner/Operator Date <br /> 1*I�AOrl t EPARTMENT <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 RENS Date <br /> FHO 1G-017 5 of 6 MFPU APPLICATION <br /> 7/1WD08 <br /> '�ECEWFD <br /> JAN <br /> �R 3 2010, <br /> PERERH�T� <br /> y�ES <br />