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_- -- _---- -- � cul <br /> - RECEIVE, <br /> N®V i 6 NIC.' <br /> ENVIROWENTIALHEALVERIFICATION OF VEHICLE COMMISSARY <br /> PERK IPSEfWl6"e provide all information requested_ An incomplete application may delay approval. <br /> VEHICLE fNFORNtATiON <br /> Vehicle Name (DBA): ` <br /> Address for Vel1ic1e: 7- <br /> Street Address <br /> 1) License Plate#: !\ 'i =/r� 1� r 4) Year: <br /> 2) Vehicfe Vin#_Jjp Ug t�/CJ j 5) Make/Model: <br /> 3) State Decal* 6) Color. <br /> VEHICLE OWNER INFORMATION <br /> Name: •ZOIC �(! <br /> Address of Owner: , S I to <br /> Street Address city <br /> The mobile food facility shalt 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 & 114257). If the use of the commissary is <br /> discontinued, the permit holder must notify this office to crake the necessary changes. Failure to notify this <br /> office may result in permit revocation and penalties. <br /> C &CJ`2 ��L ✓nom ��� /ice <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: C" - <br /> Site Address: <br /> Street Address LITtY <br /> Phone: 0 4& 0/ L 7 C 'f 1 <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 /> ensil washing sink i-! l <br /> iquid 8�solid waste disposal Store frozen food t~ iss <br /> • (2 or 3 cornparhnents) <br /> ZWreparation of food of&cold water for cleaning oitet hand washing Store refrigerated food <br /> d suppli, tovide potable watersg t parking degoate electrical oo-Pts <br /> -Signature of Commissa caner/0 erator Date <br /> HEALTH DEPARTMENT <br /> If the commissarytfood establishment is outside Sacs Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissarylfood establishment is in <br /> County. <br /> Signature of County-REHS Date <br />