Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEI ICLE 9PIF R119A7IORI . <br /> Vehicle(Name(DBA): <br /> Address for vehicle: <br /> StraetAddnas 61 City <br /> 1) License Plate# q/1 nNE _39'3 4) Year. ' / f% IV <br /> ED <br /> Vehicle Vin# C>� (�S 3 e/S� 5) Make/Model: � GED <br /> 3) State Decal# e s) Color: a EB 1 2016 <br /> NM& AL�9mci=,E oItdN€bz'91Ni'O TIARR PE HEALTH <br /> VICES <br /> Name: <br /> Address oT Owner: 1 s' S� <br /> street Addreft city <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least onceeach <br /> J operating day for cleaning and servicing (CalCode sections 994285& 994297). If the use of the commissary is <br /> discontinued, the permit holder must notify this office to make the necessary changes. Failure to notifg this <br /> officem, y result in permit revocation and penalties. <br /> tl <br /> Si na a of Vehicle Operator Data <br /> G' l6jW iISSA Ry_ - VFORHfI TtQiN7. <br /> Business Name: `+ ; �� p ,fy� <br /> Owner Name: <br /> Site Address: 20,00 L. bd yQ . C A 25205 <br /> street Addim City <br /> Phone:(ZCQ1) l t( Llk- 1-t5jQ <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at nay <br /> commissary as checked below: <br /> n Liquid&solid waste dispose{ R Utensil washing sink r ❑Store fr�n food Q Vehicle wash faclt6es <br /> (lora it washing sink <br /> IF <br /> Edfbod/lsup <br /> Hat gcoldwaterfircleaning ®Tolet&hand waehillq Q Sore refrigerated food <br /> ®Provide potable water Overnight paddng Adequate electrical dudets <br /> i <br /> Signature fof Oommissary Owner/Operator Date <br /> CiMALlHDEF <br /> AIZ MEi�iT <br /> If the commisserylfood establishment le outside San Joaquin County,the local health,urisdretion must verfy <br /> current health permit by signing below. Commissarylfood establishment is in <br /> Counfi�. <br /> i <br /> s <br /> Signature of County REHS Data I <br /> EMD 18-017 5 Of a MFPU APPUCAMON <br /> 7/18f2oae "' <br />