Laserfiche WebLink
RECEIVED <br /> AUG 09 2012 <br /> VERIFICATION OF VEHICLE COMMISSAT(VIRONMENTALHEALTH <br /> Please provide all information requested. An incomplete application may delay apppIT/SERVICES <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): U �/ �G� GR;i�Afn i <br /> Address for Vehicle: Eoil/j Rv kb 4--* _kT-041 <br /> Street Address city <br /> 1) License Plate#: ,t5F 3174F3 4) Year: � 5 ,f <br /> 2) Vehicle Vin#: 1 f 1;VF, -LfZ3JHA0$7a Make/Model: 2-&-ACIV <br /> 3) State Decal#: C/f R) Calor: <br /> VEHICLE OWNER INFORMATION <br /> Name: All T f <br /> Address of Owner: EJV v& L*W'l <br /> Street Addr ss 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 res/ulltt1 ermit revocation and penalties. <br /> n <br /> C,79 —0 <br /> Signature of Veh!GTe Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 9 C j C CA jq�n <br /> Owner Name: <br /> Site Address: ,35p-V E. E %�� C S2 <br /> Street Address city <br /> Phone: (?, r / c� <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 /> ❑ Liquid&solid waste disposal ❑ Utensil washing sink <br /> (2 or 3 compartments) Store frozen food Vehicle wash facilities <br /> ❑ Preparation of food --Zj:Sot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> ❑Store dry food/supplies ❑ Provide potable water ��Overnight parking Adequate electrical outlets <br /> PICK'N GO ICE CREAM <br /> a-D1NE;gS E. CARPENTER RD. <br /> Signature of Commissar Owner/Operator Date STOCKTON,CA 95215 <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EH©16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />