Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all Information requested. An Incomplete application may delay approval. <br />Vehicle Name (DBA): <br />Address for Vehicle:W L.. <br />Street Address 1 <br />V <br />1) License Plate#: �S� C <br />—2_ �'� f 4) Year: <br />2 Vehicle Vin #: <br />y �C {�f� i��� <br />5) <br />Make/Model <br />3) State Decal R: <br />_ <br />3 Z Gj_ :16) <br />Color: <br />Name: <br />Address of Owner: <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 (CaICOde sections 114295 & 114297). If the use of the commissary Is <br />discontinued, the permit holder must notify this office to make the necessary chan as. Failure to notify this <br />office may result in permit revocation and penalties. <br />1 G �, t`CALIFORNIACATE ING <br />SI nature of Vehicle Operator Date PLY FOOD AND: E VICE <br />"'- 2440 S. AIRPORT WA <br />Business Name: <br />Owner Name: - _ r <br />Site Address: <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 � Utensil washing sink d oo,,yy--�� <br />(2 or J compartmenlsJ Store frozen fVehicle wash facilities <br />ZPreparation of food F7rHot & cold water for cleaning ' Toilet & hand washing 'fQ Store refrigerated food <br />[Store dry food/supplies E -Provide potable water obvemight parking (P -Adequate electrical outlets <br />W1 <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 />cHO 16-017 <br />7:16/2008 5 o1 6 <br />MFPU APPLICATION <br />