Laserfiche WebLink
R Q.//l DL' (�4fnm'ls <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />',UEHICLEINF,0F2MATI0N1� rK+ <br />_. .- <br />Vehicle Name (DBA): (DII O20 L ouS ! eL C REAM <br />Address for Vehicle: 6o? 6 N . w 6 LAME K /i00 sroCkiz C/i zc <br />Street Address city <br />1) License Plate #: � O S� D(/ 4) Year: QA <br />2) Vehicle Vin #: 3N6C/y10g�(-t(,9Fk72 375) Make/Model: �J "9X <br />3) State Decal #: C J3 1-4) Color. t' -' %f <br />,'V.EFIIGrtE OWNER INFORMATION; ';_ J rte`- ^ ;� —'L .'. Ir f <br />Name: .S%Lvii]A JAZ"W SH C 5z; <br />Address of Owner:'9 0,$'C c S % &/1 C -4S ZO <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 m y result mit revocation and penalties. <br />4, � 03 - l 3 - 2-4 <br />Si rlatur of Veh le erator Date <br />[COMMISSARYJNFCRMATION , _ _.- <br />Business Name: Stoc r e <br />Owner Name: <br />2626 Westlane St NK1100 ream <br />Site Address: -262 5205 <br />(209) 469-2626 <br />StreetAddres -2073 City <br />Phone: (-&I 6 _ t � <br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: ff/ <br />F-1Liquid& solid waste disposal ❑oUfensil washing sink Store frozen food Vehicle wash facilities <br />(2 or 3 compartments) <br />❑ Preparation of food ❑ Hot & cold water for cleaningToilet & hand washing dStore refrigerated food <br />❑ Storefood/su Pr vide potable water Overnight parking �dequate electrical outlets <br />dry <br />Si nature f Commi Owner/O erator Date <br />jHEAL•-TH,DEPARTMENT t <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 idFPU APPLICATION <br />7/18/2008 <br />