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): <br /> Address for Vehicle: -29L 0 A "y u/ I 16,17 <br /> Street Address city <br /> 1) License Plate#: qCq ;e72- 4) //��Year��: / g D 4 <br /> 2) Vehicle Vin#: ��'5J0qa�Ce7Model: C//dZ--V <br /> 3) State Decal #: 6) Color: (,�f <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Ger: <br /> Street Addr ss it <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 may result in permit revocation and penalties. <br /> Si ure of Vehicle Op for Date <br /> COMMISSARY INFORMATION <br /> Business Name: tn�� t <br /> Owner Name: <br /> Site Address: tf rA- (,`r <br /> Street Address city <br /> Phone: ( ) <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 uid&solid waste disposal Utensil washing sink Store frozen food 0 Vehicle wash facilities <br /> u q p (2 r 3 compartments) <br /> Preparation of food Hot&cold water for cleaning B/Toilet&hand washing tore refrigerated food <br /> Store dry food/supplies 3 Provide potable water 2/overnight parking equate electrical outlets <br /> Si e of Commissa caner/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 />