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The Wayback Machine - https://web. archive. org/web/20160123012227/http://www. sj cehd. corn :80/doc . <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE WolgtiMION <br />Vehicle Name (DBA): ---- _ - <br />Address for Vehicle: <br />Street Address Cily <br />---1 i i ' alb Ne' f•-i License Plate #-. •:... 1 VID.,) CV! 'Y.-. 4) Year: -1!;C t 1 <br />Vehicle Vin #: 1i=0 Y.€ ci ES QP)0 A E. 4i'3-5 5) Make/Model: - C1 1--(....\V, <br />State Decal # 6) Color ‘112 ' ( <br />VEHICLE OWNER INFORMATION; , -. -, <br />Name: <br />Address of Owner: ic,;e6 ...„.-:-.L:3,1t."., RA/ e. vc tst3 ci.cd_ @A ciss2..... <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 ma It in permit revocation and penalties. <br />' <br /> <br />- - 0 ',, -1"-i- 7/-/ <br />Signature of Vehicle Operator Date <br />COMMIRSORY hoRMA1IoN ' <br />Business Name: C.4„../A 41,1, -i,,--7 <br />Owner Name: / Site Address: 6 70 , -5 ,-_-----et (t-- .-,..b--- c_5-1---- 9 s- Z-; /.. e3 <br />Street Address City <br />Phone: (24) 2 Z e 7/ - gr-__331/ <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 />hi 111‘juid & solid waste disposal P-C6---risilwasng sink t tore frozen food Vehicle wash facilities (2 or 3 com pan, . <br />9reparation of food Er- --...-.1ot & cold water for cleaning V2411/e-t & hand washing ag-t-oi-:e--refrigerated food <br />a‘dry food/supplies RT‹-ide potable water 11,:4E‘.‘night parking al'kleguate electrical outlets <br />-/5' ' a-5' <br />SignatureOr .—wnrnissaly Owner/Operator Date <br />HEAtnitiOARriktilk: <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 REFIS Date <br />EHD 16-017 <br />71182008 <br />5 of 6 MFPU APPLICATION <br />pRzsoolso <br />https://web.archive.org/web/20160123012227/http://www.sjcehd.com/docs/Verification_of Vehicle_Commissary.pdf 8 /10/24, 2:32 PM <br />Page 1 of 3