Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may�{� pt <br /> REM <br /> VEHICLE INFORMATION` - <br /> Vehicle Name (DBA): �() 6 C)G 103 <br /> f �� J <br /> Address for Vehicle: ( 7 � I( /D Ip • L�.� i � IRON' <br /> Sere et Address Ci l��`°r <br /> , ERMIT/SMI'l <br /> 1) License Plate #: 4 L C 7 Z7 5 4) Year: 2(-,)0 <br /> 2) Vehicle Vin #: Z313311751 Make/Model: LNy�N <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER'INFORMATION, <br /> Name: E ( 11-e-D lJ <br /> Address of Owner: j iU 1 9 )(& S,Z 6 <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 /> a� QU�'LI /Z5 <br /> I nit' a of Vehicle Operator Date <br /> COMMISSARY-INFORMATION: <br /> Business Name: p <br /> Owner Name: S L UR <br /> Site Address: 1717 S• I 77 S 'J C Q%dL/f 2 0 <br /> Street Address city <br /> Phone: ( ,K- ' /c <br /> I,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> IL <br /> commissary as checked below: <br /> t- r--I <br /> Liquid&solid waste disposal �tensil washing sink D <br /> ore frozen food 'vehicle wash facilities <br /> ,--,, (22 or 3 compartments) <br /> 91'reparation of food clot&cold water for cleaning 15 Toilet&hand washing Store refrigerated food <br /> Store ry food/supplies rovide potable water Q Overnight parking Q Adequate electrical outlets <br /> b - 3 S <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 - 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />