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: c c <br /> Street Address city <br /> 1) License Plate#: 3 e5L 4) year: <br /> 2) Vehicle Vin #:j�C�}�32/JiJ��33Z��ake/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: 4/ 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 /> office may result in permit evocation and penalties. <br /> 2, / <br /> Signature of Vehic e Operator Date <br /> COMMISSARY INFORMATI W <br /> Business Name: 4&e. " <br /> Owner Name: <br /> Site Address: �'"- Z,-Z <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 /> squid&solid waste disposal ensil washing sink � f;c mood ash facilities <br /> (2 or 3 compartments) <br /> reparation of food of&cold water for cleaning oilet&hand washing (� Storerefrigerated food <br /> ore od/supplies vide potable water vernight parking equate electrical outlets <br /> i 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 />