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: 2 ��� C ci <br /> Street Address City <br /> 1) License Plate#: 4) Year: �Q✓� <br /> 2) Vehicle Vin #: fv�5;DL.�E7o2/FrOI,/�JS5) Make/Model. C 9,5 <br /> 3) State Decal#: 6) Color.- <br /> VEHICLE <br /> olor:VEHICLE OWNER INFORMATION <br /> Name: 17ooz,i_ (J Cc <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 I <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@ffiature of Vehicle O erator Date <br /> COMMISSARY INFORMATIO <br /> Business Name: <br /> Owner Name: <br /> Site Address: Z 12 <br /> street Address city <br /> Phone: (Z — <br /> t, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: / <br /> iguid&solid waste disposal tensil washing sink ❑ Store frozen food1-e_hicle wash facilities <br /> (2 o compartments) / <br /> repay n of food Hot& water for cleaning let&ha washing E] Store refri rated food <br /> Sta food;su lies rovide otable water Erni hf arkin Adequate electrical out!�� <br /> rY PP P 9 P g 4 c� <br /> /013A- <br /> Si nature of Commissary 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 /> Gun za n» <br />