Laserfiche WebLink
i��,ECE-lir E <br />VERIFICATION OF VEHICLE COMMISSARY '� I " Inn'9 <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): c <br />< c• P"'t r <br />Address for Vehicle: 1 <br />Street Address Eaty <br />1) License Plate#: 'ANM-6 7 Hlc 4) Year: LG VA <br />2) Vehicle Vint. (fit, Cyt ?� 5) Make/Model: 5R CNS <br />3) State Decal #: 6) Color: <br />VEHICLE, <br />OWLVER INFORMATION <br />Name:AU, . <br />Address of Owner.�j'L\ <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 />9� tl A t�.� �'Z� V -f -26-21 <br />Si ff ture of Vehicle operator Date <br />COMMISSARY INFORMATION <br />Business Name: C - <br />Owner Name: <br />Site Address: Y f Z Y, 4�" j <br />Street Address City <br />Phone: (2e Q) 2;7y $ <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 />[quid & solid waste disposal ER'Utensil washing sink M -Store frozen food a 61icle wash facilities <br />�- (2 ora compartments) <br />I �r mparation of food �& cold water for cleaning oilet & hand washing "re refrigerated food <br />ire dry foodlsupplies [ ,P Vide potable water Q6emight parting M Mequate electrical outlets <br />Z" %— 3e �2 I <br />SI na re of Commissa 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. Commissary/food establishment is in <br />County. <br />Signature of County REHS Date <br />END 16-017 <br />717 5 of r MFPU APPLICATION <br />