Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> 11 f l'CL-i� 1�lf'O,RMME- <br /> Vehicle Name(DBA): <br /> Address for Vehicle: 73f5 'S, <br /> street address city <br /> 1) License Plate#: Zp 4) Year: r ' •j <br /> 2} Vehicle Vin#: + �(.6T '�.TN1.5�= � 5) Make/Model: LA e y <br /> 3) State Decal#: 6) Color: la <br /> 4 Name: 0 M► 6i\/ bonlylu2d 20 c13– e <br /> . I <br /> i Address of Owner: i1 U $ v) . 2 e 6-,Gl M M V\�IAi 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 (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 /> 11 office may result in perrnitLrevocation a d penalties. <br /> r1f <br /> Si6nature of Vehicle O erator'.. — Date <br /> CQI{�fAillSSA1�Y�'CNFOI�M�iTiON_: ` .. . <br /> Business Name: t yE' .t 7, ; <br /> Owner Name: <br /> Site Address: <br /> __atieet Address city <br /> i,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below:�1,� <br /> [ U u (EZ <br /> id&solid waste disposal "6tensil washing sink ❑ store frozen food ❑ Vzhide wash facilities <br /> !/. (2 or,3 compartments) - <br /> ®'Preparation of food Fl- Hot&,cold water for cleaning Droilet&hand washing ❑ Store refrigerated food <br /> dry food/supplies ' Provide potable water Overnight parking Adequate electrical outlets <br /> rl�I <br /> Si nature of -ommiss ary Owner/Operator Date <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 1M17 5 of 6 MFPU APPLICATION <br /> /18/2008 <br />