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): /22Yf <br /> Address for Vehicle: <br /> Street Address clty <br /> 1) License Plate#: /L`7 /2'��f 4) Year: /9f <br /> 2) Vehicle Vin #: /Cry �C�up/�IgJT Make/Model: <br /> 3) State Decal#: 6) Color: fZ <br /> VEHICLE OWNER INFORMATION o, qt�q 9L) <br /> Name: 4 R-T4A <br /> Address of Owner: c�6 ���r Cke-rON GA <br /> Street Address city <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once eacfi <br /> operating day for cleaning and servicing (CafCode sections 114295 & 114297). if the use of the commissary is <br /> discontinued, the it holder must notify this office to make the necessary changes. Failure to notify this <br /> offi a may re ult ir <br /> it .evocation and penalties. <br /> NU {-i-L-7 CD <br /> Si nature of cie Operafor Date <br /> COMMISSARY INFORMATION <br /> Business Name: ' l ✓K <br /> Owner Name: l/ <br /> Site Address: Cs- <br /> StreetAddress CEty <br /> Phone: <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 /> quid solid waste disposal Utensil washing sink <br /> & <br /> (2 or 3 compartments) <br /> El Store frozen food tole wash facilities <br /> epara' n of food of a cold water for cleaning oilet a hand washing ❑ Store refrigerated food <br /> Z <br /> 7ignajture <br /> ry food/supplies rovide potable water ernight parking equate electrical outlets <br /> ' of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> r1fe commissarylfood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> rent health permit by signing below. Commissary/food establishment is in <br /> unty. <br /> natu re of County.REHS Date <br /> EHD 16^017 5 of 6 W FPU APPLICATION <br />