Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORM"ATION <br /> Vehicle Name(DBA): V/ ( < /a C L " V\ <br /> Address for Vehicle: W /�S /7/Z Aw It;CA <br /> Street Address city <br /> 1) License Plate#: 4 A 3 L�kAAD- 4) Year: <br /> 2) Vehicle Vin#: 1 CACY1(g.3S/ZJ 11iQo5) Make/Model: C-HC-V S0 SLE 7 ' VA <br /> 3) State Decal* 6) Color: /i M/ TG- <br /> VEHICLE OWNER INFORMATION" <br /> Name: – •1 ' C C / AlGt h <br /> Address of Owner. e, Address(,f/N G RS AN 7C <br /> Street 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 /> �1�YX�— r M <br /> Signature of Vehicle Operator Date r <br /> COMM ISSARYINFORM`ATION <br /> Business Name: o jrc CRlEf) kn <br /> Owner Name: S 1- 7. ! - S ' <br /> Site Address: "2_V-l%V E e- CA/ G'R QV f7c C M A Sit S� <br /> Street Address city <br /> Phone: ( ) <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 Store frozen food -,g Vehicle wash facilities <br /> .� r�I (2 or 3 compartments) <br /> ❑ Preparation of food �y Hot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> ❑Store dry food/supplies ❑Provide potable water Ovemight parking Adequate electrical outlets <br /> i :7,N co rcE cArR <br /> ENTER RD. <br /> Signature of Com missgry Owner/Operator Date V 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 RE HS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2006 <br />