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): A <br /> Address for Vehicle: & G G( <br /> Street Address n ity <br /> 1) License Plate#: � BMJ- 4) Year: <br /> 2) Vehicle vin #: 7�{'3Zf tV� l� �5) Make/Model: <br /> 3) State Decal #: � 6) Color: "( <br /> VEHICLE OWNER INFORMATION <br /> Name: (/ <br /> Address o O der: <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 revocation and penalties. <br /> Si nature of Vehicle Operator Date <br /> COMMISSARY INFORMA ON <br /> Business Name: a <br /> Owner Name: . ` � <br /> Site Address: <br /> Street Address City <br /> Phone: ()O� — S '7D <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&solid waste disposal N Utensil washing sink <br /> (2 or 3 compartments) ❑ Store frozen food Vehicle wash facilities <br /> ❑ Preparation of food / Hot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> ❑ ore dry food/supplie Provide pot e wate [� Overnight parking [ Adequate electrical outlets <br /> /a -1,4 <br /> Signature of Co /missy Owner/Operat r mp. 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 />