Laserfiche WebLink
VERIFICA-OON OF VEHICLE COT 4ISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHIC�,1i;1 F �T <br /> �y�y� <br /> r9my,P kk <br /> Vehicle Name (DBA): <br /> Address for Vehicle: (fcx �� <br /> Street Address City Zip Code <br /> 1) License Plate#: � _ 41 Year: <br /> 2) Vehicle Vin#: L;,E a d�1 wyI `s Make/Model: (I <br /> 3) State Decal #: 6 Color: <br /> ,-.:'. ..,: w..A rW tru+Rd.P sy+33* inn t1.. c� •: c r �.„r o y� r. d i 4 <br /> - <br /> .., <br /> Name: - <br /> Address of Owner: o � <br /> Street Address City Zip Code <br /> The above-mentioned vehicle shall operate out of a commissary and shall report to the commissary at least <br /> once each operating day for cleaning and servicing [CURFFL 114265 & 1142871. If the use of the <br /> commissary is discontinued, the permit holder must notify this office to make the necessary changes. <br /> Failure to notify this office could result in permit revocation and penalties. <br /> - L t d tC� I a8otn. a Xa t <br /> S gnature of Vehicle Operator Date <br /> — <br /> ._ -c <br /> i�IC,.t)Izl .t`i��:,?�4.��' L.�`?Sr }��y �q;,k f 'i� <br /> .�' <br /> Business Name: <br /> Owner Name: �' G <br /> Site Address: n c� <br /> S reetAddress City Zip Code <br /> Phone: <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at <br /> my com issary as checked bel�ten*,il <br /> iquid&Solid waste disposal washing sink Store Frozen Food <br /> (2 or 3 compartments) <br /> ❑ rovide ice <br /> Preparati n of Food Electrical Hook-up Toilet&Hand washing Vehicle Wash Facilities <br /> to Dry oo Supplies Provide potable water Overnight Parking Store Refrigerated Food <br /> 1U 1 f17 <br /> Signature of Commissary Owner/Operator Date <br /> 4 <br /> tt V� ' ext }'r v <br /> - . ' <br /> I Ir .� <br /> 1"`lra. <br /> If the commissary/Food establishment is outside San Joaquin County, the local health jurisdiction shall <br /> verify current health permit by signing below. Food establishment/commissary is in RECEIVED <br /> County. <br /> OCT 2 4 2011 <br /> Signature of County E.H.S. Date tNVIRONMENTAI.H TH <br /> EHD 16-01-013 Page 8 of 8 MFF APPLICATION <br /> 5/12/2003 <br />