Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE Wt=ORMATION <br /> Vehicle Name(DBA): ti <br /> Address for Vehicle: SWZS 9, I <br /> Street Address City <br /> 1 License Plate t, 6211947Z11 J 4 Year: <br /> 2) Vehicle Vin �/ 5) Make/Model: <br /> E 3) State Decal# 6) Color: <br /> Name: <br /> Address of Owner: C <br /> u Street Addmss city <br /> a <br /> € <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> l 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. l <br /> lzna Z/ <br /> Signature of Vehicle Operator Date <br /> 1 v0MM1SSARY INFORMATION::-. '. <br /> Business Name: i 0,\ Lrw- oc)G'c 15� <br /> Owner Name: �— <br /> Site Address: 00 L I"�(?��C�.\ �.1.�; � G �Tb(1 , C� C`,-20h �. <br /> Street Address �— city <br /> Phone: (ZCCJ) <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at gray <br /> commissary as checked below: <br /> Liquid&solid waste disposal ® Utensil washing sink c <br /> (2 or 3 compartments) Store frozen food )Q Vehicle wash faclities l <br /> I <br /> ❑ Pre tion of food Hot&cold water for cleaning ©Toilet&hand washing IQ Store refrigerated food �$ <br /> Stored fuod/suppli Pr e potable water s` Overnight parking Adequate electrical outlets it <br /> l gnature of Com issa Ownerl0 erato Date <br /> If the corimissarylfood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below_ Commissarylfood establishment is in I <br /> Cau;it��. <br /> 4 � <br /> 5 Signature of Countf RSHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/16/2006 - <br />