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): ‘rie...k.-1 -.... ro <br />Address for Vehicle: \A ( i 0 0 K c k/NOtyk 5 ,to 1 yc--A 5 ac ( i- ci, (7 ( <br />License Plate <br />Vehicle Vin #: <br />State Decal #:, <br />1Street Address City <br />nt: VC,, 35( 4) Year: 2009 <br />' 5/-p-• e725613q3(0q Make/Model: i/\_) 0 -,t- ) 0,-, <br />6) Color: <br />VEHICLE VEHICLE OWNER INF4RNIAT1ON <br />Name: <br />Address of Owner: -)--) j (\f\v\ 0, c._ ../ y c \y-- C>\C: Y-3-'''`c-v\ 4-- 3 en (=A 503 <br />The mobile food facility sr <br />operating day for cleaning <br />discontinu , the rrnit <br />office may tilt i permit <br />IS <br />trei <br />Address City <br />I <br />ll operate out of a commissary and shall report to the commissary at least once each <br />and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br />bolder must notify this office to make the necessary changes. Failure to notify this <br />revocation and penalties. <br />Signature of Vehicle Ope tor Date <br />COMMISSARY INFO T1ON ,I -;;W: -*- ", 3 ---''''-' • <br />Business Name.. , ' • V ' 21-7.-\ ace, r 5-1-6, c-c- kr_Q t eve_ <br />Owner Name: (ACQ- <br />Site Address: //OD <br />Phone: /(./ ) <br />treet Address i City <br />I, the commissary owner, <br />commissary as checked b <br />j t-Liquid & solid waste dispos <br />n and will provide the necessary facilities for the above mentioned vehicle at my <br />low: <br />I 2 Utensil washing sink frozen ----Store food ..'Vehicle wash facilities <br />R'Preparation of food <br />17 Store dry food/supplies <br />( <br />(2 or 3 compartments)— <br />— <br /> Hot & cold water for cleaning ..-/-Toilet & hand washing Store refrigerated food <br />i ....Z Provide potable water E.Ovemight parking _.'Adequate electrical outlets <br />S-------C, /Le / / 7 <br />Sig ature . owner/Operator Date3 Commissary <br />4 irN <br />HEALTH DEPARTMEN . <br />If the commissary/food est <br />current health permit by si <br />County. <br />blishment is outside San Joaquin County, the local health jurisdiction must verify <br />ning below. Commissary/food establishment is in <br />Signature of County REH Date <br />5 of 6 EHD 16-017 <br />711812008 MFPU APPLICATION