Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> V�EHI:CL�E INFOR =t0 <br /> Vehicle Name (DBA): Dc> 2 <br /> Address for Vehicle: L �'h <br /> Street Address City <br /> 1) License Plate#: A4 4) Year: <br /> d <br /> 2) Vehicle Vin#: Of 4 d 5) Make/Model: (f Al <br /> 3) State Decal#: 6) Color: <br /> ,�/E_,�_,,�,, E 01NN'E INFORM�►TION _� �; �� :��� <br /> Address of Owner: e / �, <br /> treet A dress 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 revocation and penalties. �J <br /> Signature of Vehicle Operator Date <br /> Business Name: �P <br /> Owner Name: <br /> Site Address: <br /> Street Address City <br /> Phone: <br /> I, the commissary owner, can and will provide the necessary fac pities-fiir;re at my <br /> commissary as checked below: <br /> [2�Liq&solid waste disposal tensil washing sink ❑Store frozen foode wash facilities <br /> (2 or 3 compartments) <br /> reparation o of&cold water for cleaning [?�1'oilet&hand washing ❑ Store refrigerated food <br /> od foo supplies .vide potable water vernight parking �/de electrical outlets <br /> I/-V'111100�':�:� / ZU11:2 <br /> Si nature of Commiss Owner/Operator Date <br /> ""up�7f.14"A'LSitit5.. la�'ia� i` 5 �rr• A�t11= t �a <br /> HEALTH DEPA TMEIVT �. � � i �< <br /> _.�. +„4.,,.Kvi.i►�Yr.... .� csm�fi�.nv�ce.^-r�a,m c- srs .a. 'mac. ' :. •a*£ 'f -.. ..r.` '.ti t_..lY?i� <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 Aftft- <br />