Laserfiche WebLink
VERIFICATION OF VEHICLE COMMSSARY <br /> Please prcvcdr=aff friformatIca requested.- An fncompfs'M appficafion m%F,17e <br /> VEHIcLE INFORRIATiON <br /> V-88-hide Name(DBA): <br /> C D <br /> Addre—scs for Vehicle: 7 h ( <br /> 4o . <br /> 3D 147 ,CA <br /> StTemt Address City <br /> 7, 4) Year: <br /> 2) Vehicle 14n4E: <br /> 2 t4 P33y�0�33;z j M,a ke,10 0 del: <br /> a) State Decal tf : -Ccfar: <br /> VE-9CLE OMER NIF.ORMATION' <br /> .40 <br /> t Address ofZ)vvner: J <br /> C//// <br /> 77 <br /> Stwt Ada ress <br /> The mabile foordfacHity shall operate at `tOf a connm" ssary and shall report tory comr-nissary a'ISES,once •eachi <br /> L L <br /> and sanvicing 59afters 4114296 & 11124257D. If tbe use af the comm; sar ;s <br /> cZ=Cetx ff U # Ise I s y : <br /> d—isscantirtued, the permit holder =St nOU ' this Offilce to CrMkS the necessary _ChangeS. Fait ra to notfffy thLc <br /> afficema-v result in oerrnit revocation and penalUes. <br /> ArO (G-01 ro <br /> SigU <br /> ,natLre of-Vehic-le Operator Date <br /> COMM WARY INFOE1,`�.&AT10fA <br /> Business Name: <br /> Kz <br /> Name: <br /> Site Address <br /> 7, <br /> Phone: <br /> E.the comm fssary owner,can and ixul provide the necessary facilities for the above meqffoaned vehicle at smy <br /> commissary as checked below: <br /> M-66�uid&solid waw disposal r�f�Utsff Yte—shing sink <br /> (2o Store frozen Food ide wsz-f-i r <br /> r 3 cofflparkneues) <br /> fPlPr�C-ParatiOrk Of food LZ,3, of&cold water for cleaning Z<ffet&hand washing EJ_ Store refrigerated food <br /> Z-5,.C;�P7=-�d,-Yfkoodlsupplies �O�d` potable wa te rD'13_�Migfit P;eKing <br /> L <br /> Z3 <br /> Signature of Comrnissa'ny OwnerlOperator Date <br /> HES L-m DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquir. County,the local health jurisdiction must verify <br /> current health permit by signing befoune. Corr missar-yffibad esta-bifshm ent is in Ci <br /> atc-u-_of int nty.REHS Date <br />