Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide ail information requeasted. An incompie`''s application may delay aP(JTGVa.l, <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: 5M <br /> R Street address ( �/`f. Cit} <br /> 5— <br /> `i) LicensePlat-e#: � %- 1 ,' � 4) Year: <br /> 2) Vehicle Vin#�: ,�� �']g��'�j�l��t��� 5) Make/Model: <br /> - � <br /> 3) State Decal#: 7 6) Color: <br /> VEHICLE OWNER INFORMAL IQN <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 & 14297). 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 rees ttin permit revocation and penalties. <br /> Si nature,df Vehicle Operator Date <br /> COMM SARY INFORMATION! <br /> Business Name: C. '7 '. <br /> Owner Name: - ,, 3 <br /> Site Address: ;� `� aa1A S, ,� q�,.� T <br /> Lin Street Address _, Cit• <br /> Phone: ( 4��) L�L"�- L"� �-J <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 0 Utensil washing sink i ❑ Store frozen food " Vehicle v.ash facilities <br /> (2 or 3 comparments) <br /> I <br /> ❑ Preparation of food , Hot a cold water for cleaning Toilet P-hand washing ❑ Store refrigerated food <br /> ❑ iA dry food/supplies. Provide pglaple viater Overnight parking Y' Adequate electrical outlets,- <br /> 2 <br /> Signature of Corn iiia Owner/ rat-or Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must uerify <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 MFPU APPLICATION <br /> 7/18/2008 <br />