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): C M I 116 0GG S <br /> Address for Vehicle: kn.B _ fQ V, /l & /U L lq 85-36 C <br /> Street Address city <br /> 1) License Plate#: 4) Year: .26) /t <br /> 2) Vehicle Vin#: 5) Make/Model: GusTo/�q <br /> 3) State Decal #: 6) Color: G KA V <br /> VEHICLE OWNER INFORMATION <br /> Name: b RA Nit kEft MURKAr _ <br /> Address of Owner: 1166 p 6� ll kLPQW <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 may result in permit revocation and penalties. <br /> A94 t- 3 6 1 <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMAu9 <br /> Business Name: 4,AJI0 Al C I�(A) U C e—" C(J <br /> Owner Name: U r/QAteC� <br /> Site Address: 7 J 7 S /V Q 7 5 C 7 X 9S,-Z C <br /> 2rStreet Address City <br /> Phone: ( ) 2-� $ -5'/( (0 <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 /> Liquid&solid waste disposal Wutensil washing sink Store frozen food /Vehicle wash facilities <br /> (2 or 3 compartments) <br /> reparation of food [P/Hot&cold water for cleaning ®(Toilet&hand washing tore refrigerated food <br /> tore d od/supplies �ovide potable water Overni ht parki g Adequate electrical outlets <br /> Sign of Commissa Owner/O erator 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 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />