Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />�E_H- 16L�E';INFORM9�TIQN, <br />Vehicle Name (DBA): <br />Address for Vehicle: 2ro <br />street Address City <br />1) License Plate#: GL.1B}O3 4) Year: q <br />2) Vehicle Vin #: 1GC1)MI0IWft0yN Make/Model: C*A) \f AW <br />3) State Decal #: CA 6) Color: <br />[�VEFIICLE�OWNER INFORMAaT,ION -_ _ _ _ <br />Name: pG vt�L 2 Z <br />Address of Owner: 012& T T SID N SOS TOC �� VQ <br />Street Address City Goi 9 52 (G c/ <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 ma a tin permit revocation and penalties. <br />5 <br />Signature of Vehicle Operator Date <br />CQMNIIW$ARY INFORMATION. <br />- -- _ <br />Business Name: 51000W5C <br />Owner Name: CW <br />Site Address:O <br />Street Address City <br />tJ <br />Phone: (%q) �{6 _ <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 disposalUtensil washing sink I—Sto/re frozen food Vehicle wash facilities <br />(2 or 7 compartments) u ❑ <br />❑ Preparation of food ❑ Hot & cold water for cleaning oilet & hand washing ❑ Store refrigerated food <br />❑Sttoorree�ry food/ upplies ❑ Provide potable water 9.11vernight parking Adequate electrical outlets <br />. �' e ockton's Wonderful Ice Cream 5 <br />Sicinature of Cor?RMy0M4bftCI1Jf& Date <br />:�� - <br />HEALTH ©EPARTM- j>b�' 469-2626 <br />(20 4 9 -2073 - <br />If the commissary/food estSblishment 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 />7/16/2006 <br />