Laserfiche WebLink
o <br /> tv <br /> t j-q , 0 201. <br /> FNVIRQN%!ENT-'NLHEALA(ERIFICATION OF VEHICLE COMMISSARY <br /> PERNJMSERMWe provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name(DBA): <br /> Address for Vehicle: 7130 <br /> Street Address City <br /> 1) License Plate#: �!-L���j 4) Year: <br /> 2) Vehicle Vin#:Znl, �'�� c�"�/ ? Make/Model: <br /> 3) State Decal* _ 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: a i r Z vr2 <br /> Address of Owner: 10 ! ' c <br /> Street Address city <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 /> ZK1 -a <br /> S nature of Vehicle O >erator Date <br /> COMMISSARY INFORMATt¢N <br /> Business Name: c r <br /> t¢� L 'r< <br /> Owner Name: <br /> Site Address: E2 <br /> street Address Gity <br /> Phone. (Zc� t16,'l O 70 l 7 e�l _ — <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 /> Liquid&solid waste disposal ensit washing sink More frozen food ehide wash facilites <br /> (2 or 3 conVarhrrcata) <br /> gbreparation of food of&cold water for cleaning let l<hand washing ❑ Store refrigerated food <br /> f ,8f supplies Quids patabi2 water vemight parking quate electrical outets <br /> S nature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction trust verify <br /> current health permit by signing below_ Commissarylfood establishment is in <br /> County. <br /> Signature of County RENS Date <br /> can<a_n17 <br />