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): F----R 1,(7-6-A 1 4 4 1 141 A .1s- <br />Address for Vehicle: c,2 o 0 6. 5 on?( ,5---r.5, 1 o c.V TO 6.11 cii <br />Street Address City <br />License Plate #: 1 - ( Kks 8. 4 0 4) Year: ,2_ 0 / Li <br />Vehicle Vin #: 5) Make/Model: <br />State Decal #: 6) Color: GREEN 4 ezu6 <br />VEHICLE OWNER INFORMATION <br />Name: \T -Ds E T. ript az:c k N1E-a t.s ( ill /I-- <br />Address of Owner: 2 0 6, 6 5--LA-71-f 5T7 ,5' TO c K 1 6 ('s, C A <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 />office nay res I • ermit revocation and penalties. <br />Sii1ture of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: t„th 0 „t, (7f r -6. , , 1 t r 6 M a 614. A/T6g <br />Owner Name: ,y9R7-- Wit 0 77k ifip o <br />Site Address: ( 7 1 7 ,.5 , t,ti\l' f on) T. _5 7-ekl- 6 A) 4 2,5:2 o i Street Address City <br />Phone: (,20) () ? F--___s- <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 />washing Liquid & solid waste disposal R/Utensil sink Rit-ore frozen food r9<fehicle wash facilities <br />(2 or 3 compartments) <br />MPreparation of food M/Hot & cold water for cleaning HToilet & hand washing Store refrigerated food <br />r—iore dry food/supplies M‘vide potable water El tvemight parking [—PrAdequate electrical outlets <br />, <br />/0/S / // .3 - _ <br />Signature of 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. <br />Signature of County REHS Date <br />EHD 16-017 <br /> 5 of 6 <br /> MFPU APPLICATION