Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Orr Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street city <br /> 1) License Plate#: :,7 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> 1NF-Q-RMA,NTT1P,NRT, <br /> V��Zffml <br /> Name: <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 <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 /> �Ignature of Vehicle Oper&r Date <br /> PRMA,T <br /> W <br /> COMMISSARY INF, 'ION <br /> % <br /> i,-MR,"11 <br /> Business Name'. <br /> Owner Name: <br /> Site Address: <br /> Street Addr ss -clty <br /> Phone: 01YI) 7D <br /> 1, 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 19 Utensil washing sink ❑ Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food l-lot&cold water for cleaning IxToilet&hand washing ❑ Store refrigerated food <br /> ❑ ore food/supplies Provide potable water ❑ Overnight parking ❑Adequate electrical outlets <br /> food/supplies <br /> s- <br /> :or 'L <br /> Is <br /> Slignature of Commis aryy Owner/Ope4ratr 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 MFPLI APPLICATION <br /> 7/18/2008 <br />