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): EL T4CQ L eD GO <br /> Address for Vehicle: (gtlL/o �. f ('f <br /> Street A`d7dress Cid, <br /> 1) License Plate#: 9.50 A A 3 4) Year: f g 3 e <br /> 2) Vehicle Vin # 16DHh3a. QWr 5-0Ii0bq 5) Make/Model: 6MC <br /> 3) State Decal #: 6) Color: I Z <br /> VEHICLE OWNER INFORMATION <br /> Name: ft\r f 0 e . d tt 11 r s1 nA i <br /> Address of Owner: IIGI05 j: ,ftQ,t.V-\i(10 St_ tcr(u, Y <br /> Street Address 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 /> Ili —2C,?--0Signa urs of Vehicle Operator Date <br /> COMM! SARY INFORMATION <br /> Business Name: �� ICor i<N C. <br /> Owner Name: �G I vc \"r <br /> Site Address: Ztl I) <br /> Street Address City <br /> Phone: (20 S <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 !S(tonsil washing sink 7�4tore frozen food Vehicle wash facilities <br /> ,—,/. (2 or v mmpartmenfs) <br /> � <br /> Preparation of food Eliot& cold water for cleaning D-toilet&hared washing lKstare refrigerated food <br /> Store dry food/supplies Provide petabie waterOvernight parking _J Adequate electrical outlets <br /> ) v z <br /> Signature of Commissary Owner/Operator Date <br /> HEALTH ®EPARTMENT <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 /> i, <br /> EHD 6-017 Sof o' <br /> 7/18!2003 NIFPU APPLICATION <br />