Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> "VEtICL-E INFORMATION <br /> Vehicle Name (DBA): T C S q Ma IM Toi WYMW <br /> Address for Vehicle: 0 S (RUrOMM A b� <br /> Street Address city <br /> 1) License Plate#: 15�Z I M 1 4) Year: <br /> 2) Vehicle Vin#: ���jK��J21�� �j���j� 5) Make/Model: <br /> 3) State Decal#: �/� 6) Color: hI QJ <br /> VEHICLE OWNER-rNFORMATION <br /> Name: aSn[A my <br /> Address of Owner: AM WU <br /> i Street Address city <br /> i <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 & 1142971. If the use of the commissary is <br /> discontinued, the p h must notify this office to make the necessary changes. Failure to notify this <br /> ice may res in pe revo tion and penalties. <br /> Si natur of Vehic e O ator Da e <br /> GOMMISSARY.INFORMATION <br /> Business Name: Gul ffnjol WINSi l <br /> Owner Name: WIVOR Nffirostrb <br /> Site Address: '�O a � ST <br /> street Address city <br /> Phone: (1,01) 273 $ <br /> 1,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> com issary as checked below: <br /> p �tensil washing sink <br /> Li uid&solid waste disposal or 3 compartments) ore frozen food Vehicle wash facilities <br /> Zs9o'e* <br /> on of foodWHct5Pr <br /> cold water for cleaning T ilet&hand washing ❑ Stpre refrigerated food <br /> food/supi e potable water Overnight parking [Adequate electrical outlets <br /> Si ure of Co er) r <br /> Ownator Date <br /> r-9R f 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 /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />