Laserfiche WebLink
VERIFIctrION OF VEHICLE CAMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE: INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Addf�ess rj(� sN l �S` D <br /> 1) License Plate #: S q� 4) Year: ZC0 <br /> 2) Vehicle Vin #: 5) Make/Model: fti C <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: � C_) uadW 1 Q <br /> Address of Owner: I1 FT SOUTDV\ <br /> Street Address J i 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 cleanjng and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinued, the ermt holder must notify this office to make the necessary changes. Failure to notify this <br /> office may r�es­att '' per' t rev ation and penalties. <br /> 3 dol <br /> Signature of V41­II e O rator Dat <br /> COMMISSARY INFORMATION <br /> Business N me: <br /> Owner Name: ----� <br /> Site Address: �— J, <br /> Street Address City <br /> Phone: ( ) <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 /> Liquid &solid waste disposal 9 Utensil washing sink i <br /> q p (2 or 3 compartments) Store frmzU ��u F e i•le- <br /> ca � �i/pti _. f <br /> 2440 S. IRPORT WAY ll�� <br /> Preparation of food Hot& cold water for cleaning Toilet& hq asjicc gto®^rer4ePated , <br /> I w (2 466 9000 .. ..►.._,.: <br /> Store dry food/supplies Provide potable water FIZOvernight parking Adequate electrical outlets <br /> Signature of Commissa Owner/Operator Da e <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 MFPU APPLICATION <br /> 7/18/2008 <br />