COMPLIANCE INFO_2018 - Laserfiche WebLink

Home Browse Search

VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. �IEH ICLE )NFORMAT_I_O_ '� v a� t '41 Vehicle Vehicle Name(DBA): Address for Vehicle: 7 3C5 Street Address // city I 1) License Plate#: 7�-� �lO 4) Year: f 7 2) Vehicle Vin#: (f Make/Model: 3) State Decal#: v 6) Color: l t i NEFIWCLEROWIVER INFORMATION� ��9_� `;�� .# .. �'_.,� . ,C Name: — / Gj Address of Owner: Street Address city The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing (CaiCode sections 114296 & 114297). If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office may result in permit revocation and penalties. A , 'F, y .3 /1 //-e?5 Signature of Vehicle Operator Date Business Name: Owner Name: SiteAddress: 7 /r G --Street Address city Phone:[ C�� Z I,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: E1115q-uid&solid waste disposal tensil washing sink ❑Store frozen food ehide wash facilities (2 or comparhnents) repa n of food Hot&cold water for cleaning Toilet&hand washing ❑ Store r figerated food ore food/supplie s /J Provide potable water Overnight parking equate electrical outlets Si nature of Commissa OwnerlO erator Date r.53cs'` - ,.,oxFpS � '? - da r T.+ n �,a ,"F,� .ne ;k..�yW z RX , I�EALTH D R 4RTMENT, , ' « _ F m �.,.._.... .�1 Y`tn 26'�. c.s.. .:..,._ If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify current health permit by signing below. Commissary/food establishment is in County. Signature of County REHS Date EHD 16-017 5 of 6 MFPU APPLICATION 7118@008