Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An Incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): C 6-FOO G S <br /> Address for Vehicle: ER 6' 77 / Af ,>' 9 33 r- <br /> Stree/t/Address city <br /> 1) License Plate#: it KE 92147 4) Year: 2 b (,S- <br /> 2) <br /> S2) Vehicle Vin#: 5) Make/Model: 5 A C IV <br /> 3) State Decal#: 6) Color: STi10LE5S '5-- E(— <br /> 'VEHICLE <br /> 5-- (-"VEHICLE OWNER INFORMATION; <br /> Name: , C— FC <br /> Address of Owner: u R $ (V �G ef C-4 9 533 <br /> Street Address City <br /> The moblie 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 (CaICOde sections 114296 & 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 pe It revocation and penalties. <br /> 711311,s-- <br /> Sign re of Ve icle O erator Date <br /> COMMISSARY INFORMATION <br /> Business Name: (, l D C IU` -D u C CCN L R <br /> Owner Name: L (" O k A ,0 D <br /> Site Address: ,o/r D 1 S T STb Ck-1Z9 e/f <br /> 2D q <br /> Street Address City <br /> Phone: <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below:7 <br /> [ LI'quid&solid waste disposal Utensil washing sink tore frozen food DlVehicle wash facilities <br /> (2 or J compartments) <br /> [ reparation of food [L14Klot&cold water for cleaning [3116�1et&hand washing © Store refrigerated food <br /> Store food/supplies rovide potable water E Overnight parking Adequate electrical outlets <br /> 3 /5 <br /> Si nature of Commissary Owner/Operator Date <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. Commissarylfood establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHO 16-017 Sofa MFPV APPLICATION <br /> 7/18/2008 <br />