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):;6_ v c..1 <br />Address for Vehicle: . 2 6 /l,. V-/ L.,,f-Ave- #4: 5/0a0A) <br />Street Address City <br />License Plate #: 4/I/A/2. 3 0 / 4) Year: 700:7 <br />-' —5- Vehicle Vin #: 1-6, 4U 5 0 V / •"?--r_36 ,$) Make/Model: /PA< <br />State Decal #: e,9- 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name:3,e <br />Address of Owner: it kik (ki N,,--k- -rc cA._,_K Oc S4c)c-4 0 (UP <br />Street 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 />offi may result in permit revocation and penalties. <br />_ <br />ignature o Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: 9144.-b yl. Wov*wC\A 4 c,,Q 4-Q ok.i,,\A_ <br />Owner Name: ek vic( clip umwe.A7 <br />Site Address: gb p(p N. L,Lies+ Lai.e L5bil.e <br />Street Address City <br />Phone: a% q (O b&7 9..k,x0 <br />I, the commissary owner, can and will provide the necessary facilities for the <br />commissary as checked below: <br />rKtensil washing sink liquid & solid waste disposal S re frozen food (2 or 3 compartments) <br /> Preparation of food Mv•Flot & cold water for cleaning T !let & hand washing <br />n Store dry food/supplies Provide potable water Overnight parking /1 — <br />.4r <br />above mentioned vehicle at my <br />hicle wash facilities <br />tore refrigerated food <br />Adequate electrical outlets <br />Signature of ommissary Owner/Operator Date <br /> <br />HEALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local <br />current health permit by signing below. Commissary/food establishment is in <br />County. <br />health jurisdiction must verify <br />Signature of County REHS Date <br />EHD 16-017 <br />5 of 6 MFPU APPLICATION <br />7/18/2008