Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY ..; <br /> Please provide all information irequested. An incomplete application may delay approval. <br /> ........ .,.. _.. - .. .-a•.,�-'�.:' 4.:rF"`_F'2ilz^"".'= .?c'�� F,-ri' ..K�m'.aY'_.-:� 1i$ _ . F3'E?., <br /> 4 r. o-y F•r '�A 9 a-. <br /> �VEfiI,GL_ E�INFO,RMA710N����-•+ �;, ,+' <br /> Vehicle Name (DBA): Vedo, 5r/�5 t r"irl C-1 rrl <br /> Address for Vehicle: 12.EC.kv tom. `) - I' -e- <br /> Street Address C(ty <br /> 1) License Plate#: 7. 171 2>< - 4) Year: <br /> 2) Vehicle Vim#: 16 iJi;P 32 9t-35ov 0� 1 5) Make/Model: I'11c, T.l p<a-i'1 <br /> 3) State Decal * 6) Color: �l a 1l 0 u �u <br /> 1 <br /> Name: P d(o Ovi `' —OIA <br /> Address of Owner: 5 +CF.( SC C <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 i(CalCode sections 114245 & 114247). 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 /> offic may retult in•pe t revocation and penalties. <br /> nature of Vehlcie Operator Date _NE <br /> n = R <br /> GOM�JII$SQRY�{NFORMATIbNk <br /> a. k� <br /> Business Name: <br /> a ��• -� <br /> Owner Name: i brag Inc <br /> h� �r�S4 <br /> Site Address: Sacramento, CA 95811 h <br /> street Address City <br /> Phone: Pl ) Lie-, 7 <br /> 1,the commissary owner, can and will provide the necessary facilities for the'above mentioned vehicle at my <br /> commissary as checked below: <br /> /❑ Utensil washing sink Store frozen food E/ Vehide wash facilities <br /> 0 Liquid&solid waste disposal IZ or a compartmental I <br /> / <br /> 9/ Preparation of food UHot&cold water for cleaning [:]"Toilet&hand washing Store refrigerated food <br /> I eli <br /> Q/ Store dry food/supplies ❑/ Provide potable water © Ovemight parking []Adequate electrical outlets <br /> 1 <br /> SI nature of Commissary Owner/O erator Date <br /> 1`arts <br /> '�{1�R;L"TiFi`.QE�ARTMENT,.�"T "�,�.. � i�f�..'-�<``' S" 'z' „�� . �-•, ,,�� Ni�: <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 /> 7/182008 <br />