Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: / C <br /> Street Address City <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin #: �� ��y�1r�3��' % 5) Make/Model: <br /> 3) State Decal #: P <br /> 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: - 1�11 <br /> i <br /> Address of Owner: r C- <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 apd servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinued, the permit holder must notify this office to make the necessa changes. Failure to notify this <br /> office ay - ult' er vocation and penalties. <br /> I nature of Vehicle rator Date <br /> COMMISSARY IN RMATION <br /> Business Name: _ <br /> Owner Name: <br /> Site Address: <br /> f r �, <br /> street Address City <br /> Phone: (f��y) <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 /> 14 iquid&solid waste disposal ❑ Utensil washing sink <br /> (2 or 3 compartments) ❑Store frozen food \❑/ Vehicle wash facilities <br /> ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washing7� <br /> ❑ Store refrigerated food <br /> ❑Store dry food/supplies 77 Provide potable water Overnight parking F;t Adequate electrical outlets <br /> Signature of Com missa Q n4rr.operator 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 RE HS Date <br /> EHD 16-017 <br /> 7/18/2008 5 of 6 MFPU APPLICATION <br />