COMPLIANCE INFO_2017-2018 - Laserfiche WebLink

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RECEIVED NOV 0 8 2017 ENVIROWENTA.HMVERIFICATION OF VEHICLE COMMISSARY PERMIT'SERVN%e provide all Information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): la(,U Sr- Address for Vehicle: 7 C) -3 Street Address city 1) License Plate* 6(,::�, 4) Year: 21 Vehicle Vin#: tO BW,3 9,M 5-:F33 5) Make/Model: CLr e 3) State Decal#: 6) Color: VEHICLE'OWNER INFORMATION , Name: I S C c� SCG lG\ Address of Owner: 11? tiCAM CAA T Street Addmss city The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this 7ce may result in permit revocation and penalties. �) //Api Signature of Vehicle Operator Date COMMISSARY INFORMATION Business Name: ` Owner Name: Site Address: O & 95-aQ 3 Street address Cl Phone: (Z `j 9 c�2`11 l 7 i,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: ffieg-Liquid&solid waste disposal Utensil washing sink ❑(2 or 3 compartments} Store frozen food ehide wash facilities - M�P repar tion of food of&cold water for cleaning oilet&hand washing ❑ Store refrigerated food tar dry food/supplies ❑ Ovide potable watervernight parking quate electrical outlets Signature.of Commissary Owner/Operator Date HEALTH DEPARTMENT If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify current health permit by signing below. Commissaryffood establishment is in County. Signature of County REHS Date