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): ClAssic <br /> Address for Vehicle: (3LE/v t7 CT- <br /> Street Address Cly, <br /> 1) License Plate#: y1�?j152(o9 4) Year: 200 4� <br /> 2) Vehicle Vin#: 5) Make/Model: AJ-1q M& <br /> 3) State Decal#: 6) Color: $�/yLFSS �7�EL <br /> VEHICLE OWNER INFORMATION , • ` <br /> Name: kt'LLVp LL UE7TE 1� LL <br /> Address of Owner: 35 GLEAJ)170 <br /> Street Address h, <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 pe revocation and penalties. <br /> W J <br /> Signature o;kehicld Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 0 C — l(/16 TRUCk (fN <br /> Owner Name: �J p <br /> Site Address: S' 111VID6 SE 157—Qk— 6 ZQ� <br /> Street Address Clty <br /> Phone: (��) 2 2ff- <br /> I,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below:: y <br /> Liquid&solid waste disposal LJ utensil washing sink <br /> (2 or 3 compartments) Dt'tore frozen food aVehide wash facilities <br /> Q Preparation of food ER Hot&cold water for cleaning �ilet&hand washing Store refrigerated food <br /> tore dry food/supplies EB Provide potable water Q Ovemi h7pa',ing Q dequate electrical outlets <br /> Si nature of Commissa Owner/Operator Date <br /> HEALTH DEPARTMENT ' r <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 /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />