Laserfiche WebLink
VERIFICA71ON OF VEHICLE COIIMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />, <br />Vehicle Name (DBA): (16.' •)//(0 75 <br />.e. — <br />Address for Vehicle: 2" FZ0/2/1.P/) /)(t )'9 Cg-Tagt*/ <br />Street Address <br />..-- <br />t Li- 4 1\ ) <br />% <br />License Plate #: , <br />City Zip Code <br />- - - -77; Year: <br />Vehicle Vin #: I 2- 2- 2- c75'6 5) Make/Model: —rail /1A <br />State Decal #: 1/5 03 0/ 6) Color: <br />rn .(-F N 0-1212_e;boba <br />A L/E-_.-trAk.:( C.-/ E. 75 <br />i Name: A ithk— L t5 N. U 170 <br />Address ofOwner: 2...7 z4 FL.O /2/ Dd.3 <br />Street Add, ess City Zip Code <br />The above-mentioned vehicle shall operate out of a commissary and shall report to the commissary at least <br />once each operating day for cleaning and servicing [CURFFL 114265 & 114287]. If the use of the <br />commissary is discontinued, the permit holder must notify this office to make the necessary changes. <br />Failure to notify this office could result in permit revocation and penalties. <br />....--.0.-/ r s ,.. . ehicle Operator Date <br />0516111VgAff417:615"'Witila , # - ..!-.., , t.4.,- ,, ' <br />Business Name: — ate- IV( di >. koul4 <br />Owner Name: , N- e- A bkAyov y a&GtA.__ ... . <br />Site Address: 17 t a° ir R2- <br />StreetAddress City Zip Code <br />Phone: (lc ti ) ('11 4 t - 2,7-5 0 Or Ze (:2 .- 0 2-/- I <br />I, the commissary owner, can and will provide the <br />my commissary as checked below: <br />Liquid & Solid waste disposal Utensil washing sink <br />(2 or 3 compartments) <br />, <br />P reparation of Food 7Electrical Hook-up <br />Store Dry Fsod/Supplies 71 Provide potable water <br />:—.....morvilmai pra"tglI-- <br />necessary facilities for the above mentioned vehicle at <br /> Store Frozen Food V Provide ice <br />liToilet & Hand washing Vehicle Wash Facilities <br />_ <br />VI Overnight Parking Store Refrigerated Food <br />7.- / ( I 7_ sfi: .--iu•r-7.0-7-0mm-lssary Owner/Operator Date <br />. ..,> i • J1EAI1TITlDEPAITMENI'ir-- _, s-,. -, , )-.-' ,. <br />If the commissary/Food establishment is outside <br />verify current health permit by signing below. <br />County. <br />San Joaquin County, the local health jurisdiction shall <br />Food establishment/commissary is in <br />Signature of County E.H.S. Date <br />EHD 16-01-013 <br /> Page 8 of 8 <br />MFF APPLICATION <br />5/12/2003