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):' 13 671-c- ( 4 Mit M ,5-/-/A /a) <br />Address for Vehicle: <br />Street Address City <br />License Plate #: EJ 4/036:3 3 4) Year:1 9 75- , i <br />Vehicle Vin #: 6 PI 2-55-11 3 00 70 y 5) Make/Model: C rrY1 i f/1-11 <br />State Decal #: 6) Color: VertCGRAi <br />VEHICLE OWNER INFORMATION, ( 7-4 1) clac <br />Name: 771-4--2 ID, . C-144C. 4N4 g-eiva... stit'C R/K_ <br />Address of Owner: /0 ?55"-- 5-4-1(ey ca.( a- 5 -cr cic_TZ sAJ CA- 9 5- 2_0( 7 <br />The mobile <br />operating <br />discont'nue <br />office <br />Street Address City <br />food facility shall operate out of a commissary and shall report to the commissary at least once each <br />day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br />, the p mit holder must notify this office to make the necessary changes. Failure to notify this <br />y sult ' p rmit revocation and penalties. <br />In , / / <br />rSjEajure o ehicle Opera Date <br />COMMISSARY INFORMAT)ON . <br />Business Name: 4, <br />Owner Name:4/„, el ei ..• ..--z, <br />Site Address: 47/17/0 ,5) A 1:P6,14 <br /> <br />Street Address Address City <br />Phone: (74,9 4/7 7042j) eel/ 7V— a:2 7 ,;2-1/ i 7 V <br />commissary <br /> Prep . <br />Store <br />I, the commissary <br />Liqui5,&solid <br />owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />as checked below: <br />I-4 is waste disposal ;l washing sink 11 Store frozen food Vehicle wash facilities <br /> <br />(2 or 3 partments) ... <br />argtion of food Ot & COld water for cleaning oilet & and washing -- Store refrigerated food <br />food/supplies 1-474:e potable water Rrnight parking Adequate electrical outlets <br />,....y,2 .:.!..----7,--- - <br />/ a, / ig, 7 11 -4-- <br />Signature of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <br />current <br />County. <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />health permit by signing below. Commissary/food establishment is in <br />Signature of County REHS Date <br />EHD 16-017 5 of 6 MFPU APPLICATIDN <br />7/18/2008