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): (xn, i,s C -e, Cy -cavo <br />Address for Vehicle: (JV rt,✓L (G\e- Ave C <br />Street Address City <br />�j <br />1) License Plate #: 'I V �'I(0-` 2 4) Year: l �� <br />2) Vehicle Vin #: NWA 33J2 -44L jD 5) Make/Model: eV <br />3) State Decal #: -a.. — 6) Color: iNln tt � <br />VEHICLE OWNER INFORMATION <br />Name: L Z pFti (A( a LLA -a <br />' ' � <br />Address of Owner: iz� GIA I'VO l G`. /-rf, S. 'Z ,t - v'�J <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 (CaICOde 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 />k/e Z LG(c, d / - ck <br />Si nature o Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: <br />Mnde u 11 ream <br />Owner Name:00 ' 2626 Westl <br />Site Address:, St I <br />L <br />Stockton, California 95205 <br />treet Address c 9) 469-2073 <br />Phone: (�`1) 6 `� - 2 6 2.E <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 ❑ Utensil washing sinkStore frozen food [2-Ve—hicle wash facilities <br />(2 or 3 compartments) <br />❑ Preparation of food ❑ Hot & cold water for cleaning Toilet & hand washing Store refrigerated food <br />n <br />❑ Store dry food/suppli rov' a otable water E Overnight parking L1 r dequate electrical outlets <br />�-z7-7- <br />Si natur40m� miss ner/O erator Date <br />HEALTFf 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 />