Laserfiche WebLink
VERIFICATION OF VEHICLE COiviMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): /,'„) <br />, <br />Address for Vehicle: 3 / <br />ocreet Address <br />4,2;1 <br />c15 -Y2 <br />City <br />License Plate #: S ‘.3.- $ (-1 4) Year: <br />Vehicle Vin #: "? .„; , 6- • 5) Make/Model: <br />State Decal #: <— 6) Color: <br /> <br />7 <br /> <br />h t- y p o <br />P <br /> <br />VEHICLE OWNER INFORMATION <br /> <br />Name: <br />Address of Owner: y‘o <br /> <br />City <br /> <br />Street Address <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 />- <br />Signature of Vehicle Operator <br /> Date <br />COMMISSARY INFORMATION <br />Business Name: Cy 415( <br />Owner Name: d., 1--a- titsi-aiy <br />Site Address: S r e;1_,A V.114\0 1\1 ps ktf8 AciusleA.E,0 G. c <br />Street Address <br />City <br />a13 t <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 />Frt Utensil washing sink rxi Store frozen food <br /> IT Vehicle wash facilities <br />[Y1 Liquid & solid waste disposal <br />(2 or 3 compartments) <br /> Store refrigerated food <br />En Hot & cold water for cleaning F-7 4 Toilet & hand washing <br />Rd Preparation of food <br />g Adequate electrical outlets <br />MI Provide potable water S Overnight parking <br /> Store dry food/supplies <br /> <br />3 —d-6 / <br /> <br />Date <br /> <br />Signature of Commissary Owner/Operator <br /> <br />HEALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />surrent health permit by signing below. Commissary/food establishment is in <br />k,ure of County RENS Date <br />/7 <br />5 of 6 <br />MFPU APPLICATION