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): P✓r�–t z-`�-- <br /> Add ress for Vehicle: 3 ' <br /> Street Address City <br /> 1) License Plate#: �.C<�) 4)) Year: l 9 <br /> 2) Vehicle Vin#: lC?Tc-- o1 Make/Model: 6.A-� <br /> 3) State Decal#: 6) Color. _�(c <br /> VEHICLE OWNER INFORMATION <br /> Name: �' Lo <br /> Address of Owner: / — <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. f=ailure to notify this <br /> office may result in permit revocation and penalties. / <br /> 4.3 <br /> Signature of Vehicle Operator Date 1 <br /> COMMISSARY INFORMATION <br /> Business Name: G <br /> Owner Name: <br /> Site Address: G <br /> Street Address `! <br /> Phone: ) 7/ <br /> f,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> quid 8solid waste disposal tensii washing sink Store frozen foodehicie wash facst es <br /> (2 or 3 compartrnentr) <br /> reparation of food of&cold water for deaning oilet& hand washing E] Store refrigerated food <br /> dry food/supplies rovide potable water vemight parkingquate eiectncal outets, <br /> /0 /,f3ig <br /> nature of Commissa Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> if the commissaryffood 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 />