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): R W G k S /MT 006,5 <br /> Address for Vehicle: 3'63D FNY U,6c—/K L2A S 1&0((D—N C fi ?,5—RIO <br /> Street Address City <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 6) Color: C dm&E <br /> VEHICLE OWNER INFORMATION <br /> Name: /N7-OV/ 6 /{LC� NDRe.e PEE7? <br /> Address of Owner:vj 630 60x S`T6Ck1Tb(J e2 C2— <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 CKY forcleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinu the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office maysu in permit revocation and penalties. <br /> r /Z1 <br /> SiqWup4 of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: (/j/(//p/ CHTzR G CE91'L-k <br /> Owner Name: 6&0 %//'XCJ 6 <br /> Site Address: / 7/7s, u 110IJ -577 STOC 6/1I -,4 9SoZO b <br /> Street Address City <br /> Phone: (SOT J2 - sTq/I/— <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> QLiquid&solid waste disposal EP-ZUtensil washing sinktore frozen food E Vehicle wash facilities <br /> (2 0 3 compartments) <br /> paration of food Hot&cold water for cleaning E Toilet&hand washing Store refrigerated food <br /> ED Store dry food/suppliesProvide potable water z/Ovemig it par ring Adequate electrical outlets <br /> / 9c�C t� / <br /> Signature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT i <br /> If the commissarylfood 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 /> EHE 16-017 5 of 6 MFPU APPLICATION <br />