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): /Las- ioz -7,z3cs _ 5_5- 0ig-r6 - - k //1/6 <br />Address for Vehicle:3/=23 j] 655A Wil tr) --1-•-& /7 -434/ 60_ iq2. 6 _c--- <br />Street Address / City <br />License Plate #: 99'i'742. 4) Year: / 9 'I 2( <br />Vehicle Vin #: 5) Make/Model: ( fil C <br />State Decal #: 6) Color: iee_ik__K <br />VEHICLE OWNER INFORMATION <br />Name: 5 /9 t i ( 1., C. 1-1 4 ki 62 <br />Address of Owner: ,3 1 zj 0 14 it) 6:75,5,9 ki )/9 () /mili e4 <br />Street Address 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 mai res 1 in rmit revocation and penalties. <br />/ t <br />)- / 7 7 y <br />Signature of Vehicle Op ator Date <br />COMMISSARY INFORMATION <br />Business Name: (i4,i/p4) 1:77 7--g•itV/VG -7-Rad<, C6-71,17-6 -1'Z <br />Owner Name:,57/2:_ ,,,,,,o, -7---FIV4-‘,61 3 <br />Site Address: (" 7 / 7 5 . i,,,,,v, 04 j 51-: (6 c-KTO Ai C 6 <br />2z)Street Address ) City <br />Phone:( -3— 6 / l 6 <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 />..- <br />,---,, ..-- <br />l Liuid & solid waste disposal EKUtensil washing sink [1711'tore frozen food r9</ehicle wash facilities (2 or 3 compartments) , <br />ri-Pfejoaration of food IC Hot & cold water for cleaning -toilet & hand washing Store refrigerated food <br />dry food/supplies 1-9‹-ovide potable water RO\Vremight parking Adequate electrical outlets <br />' <br />/ // 7 / I gr- <br />Signature :Commissary 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'. i <br />- . . <br />Signature of County HS Date <br />EHD 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008