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): Triple J <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate* YSN li 50 LA 4) Year: 2018 <br /> 2) Vehicle Vin #: 4M9U1U2C8JSO43063 5) Make/Model: <br /> 3) State Decal #: 6) Color: WHITE <br /> VEHICLE OWNER INFORMATION <br /> Name: Julio Rodriguez <br /> Address of Owner: 13 358 Gina Dr Lnrkpforcl Ca 95237 <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 & 114297). 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 result in permit revocation and penalties. <br /> Signal re ehicle O erat rl�ff Date <br /> COMMISSARY INFORMATION <br /> Business Name: Commissary Azteca <br /> Owner Name: <br /> Site Address: 620 S Sacramento St Lodi CA 95240 <br /> Street Address City <br /> Phone: (209) 224-8334 <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 /> [D/Liquid&solid waste disposal Utensil washing sinkStore frozen food Vehicle wash facilities <br /> (2 or 7 compartments) <br /> ❑ Preparation of food -lot&cold water for cleaning oilet&hand washing L Store refrigerated food <br /> tore dry food/supplies 'Krovide potable water vernight parking dequate electrical outlets <br /> W -30 -167 <br /> Si nature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT, f - .• <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 />