Laserfiche WebLink
tia- <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION . <br />Vehicle Name (DBA): (f J A % Ce (:fR CAS <br />Address for Vehicle: �)- 146 C4 Co 0 5{-i Q -t <br />V\ <br />Street Address <br />city <br />1) License Plate#: 4T-> W 5 2.9 4) Year: <br />Zoo 3 <br />2) Vehicle Vin#: JGtC(yti--15V'01'2-OgNq) Make/Model: <br />Q- C -V 32U <br />3) State Decal #: 6) Color: <br />1-7 C <br />VEHICLE OWNER INFORMATION' <br />Name: �kSOAD <br />Address of Owner.2 0 <br />Y -)Street <br />Address <br />City <br />The mobile food facility shall operate out of a commissary and shall report to the <br />commissary at least once each <br />operating day for cleaning and servicing (CalCode sections 114295 & 114297). <br />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 />tilARSIRPIP <br />Signature of Vehicle Operator Date <br />06MMISSARY_ INFORMATION <br />Business Name: <br />Owner Name: <br />Site Address: <br />Street Address <br />city <br />Phone: ZQgI (DC <br />the iWiITC196U�and will provide the necessary facilities/for the above <br />w. <br />Stockton, California 95205 _TT ��/tvsil/Store <br />mentioned vehicle at my <br />/Vehicle <br />Li l 91 ME disposal washing sink frozen food <br />1208 as 2 3 compartments) <br />wash facilities <br />Z11,& hand washing <br />❑ Preparation of food cold water for cleaning7.vernight <br />❑ Store dry food/ pplass ❑ Provide potable water -parking <br />❑ St e refrigerated food <br />Adequate electrical outlets <br />2� <br />Si nature of Commissa 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 />