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): PAPAA <br /> Address for Vehicle: 3592 C Ake&a-E9, �� p 0W 21 <br /> Street Address city <br /> 1) License Plate#: (a lz'& --,Y- [p%('0 4) Year: <br /> 2) Vehicle Vin #: 1 GTi=67 ICK 7A)l7(po k<D 5) Make/Model: �MC <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: MAO ASIF <br /> Address of Owner: 5uo WATERLOO 0 _._ — _ _5�� �� P5-2 5 <br /> Street Address Ciry <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 /> Mot �� SI� Iz - (2 _ i <br /> Signature of V icle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: ,• _ ' <br /> Owner Name: <br /> Site Address: 12 <br /> q <br /> Street Address City o� <br /> Phone: ( ) l� '� a, <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 grstore frozen food <br /> (2 or 3 compartments) Vehicle wash facilities <br /> ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> ❑ Store dry food/supplies Krovide potable water Overnight parking `-Adequate electrical outlets <br /> PICK'N CO TCE C-77AM <br /> 35U3E C.' '.7. <br /> Signature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <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 />