Laserfiche WebLink
Liquid & solid waste disposal <br />Preparation of food <br />oStore d f-o d/supplie <br />Utensil washing sink <br />(2 or 3 compartments) <br />Ve potable water <br />t El Store frozen food Vehicle wash facilities <br />Store refrigerated food <br />Adequate electrical outlets <br />Hot & cold water for cleaning 5<1 Toilet & hand washing <br />Overnight parking <br />// --(74; <br />gnature of Corn issary OwTier/Operato Date <br />ALTH DEPARTMENT <br />Date <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): &Mt/ <br />Address for Vehicle: 621w e <br />Street Address <br />76"-c-ef ,t_d_.efir <br />Air 14/42-et / ZW' 75-3 I <br />City) <br />License Plate #: ,71e) W 4) <br />Vehicle yin #: 6,,cu pgri .3s-z) /21 5) <br />State Decal #: 6) <br />Year: <br />Make/Model: <br />Color: <br /> <br />Name: <br />J:11c) <br />City <br />Address of Owner: <br />VEHICLE OWNER,INFORMATION ai • <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 />c <br />frr( <br />Signature of Vehicle Operator <br />COMMISSARY iNFORIVIATION <br />Lc <br />., e--, <br />0_._c C_,..\. a, 1 <br />R. , L......C)<": \D0c,:s DA- Son <br />C . \...,—),, , or\ ., p , /..\,c .(\c„.,, ...k...k ,3 c. <br />2°O(f. 1-0,ca.-\ rls C A ci 5 '2,i) r—.J <br />. Street Address I . city <br />Phone: (2C,CA) 1,1 (0LA - i•A 5 i 0 <br />, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />Business Name: <br />Owner Name: <br />Site Address: <br />if the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />current health permit by signing below. Commissarylfood establishment is in <br />County. <br />Signature of County REHS <br /> <br />Date <br />EHD 16-017 <br />708(2005 <br />MFPU APPLICATION! 5 of 6