Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: y p _ 4) Year: <br /> 2) Vehicle Vin #: I f��4 i+,—'rr�or�e� �� Make/Model: <br /> 3) State Decal #: _ 6) Color: <br /> t 3 <br /> Name: <br /> Address of Owner: q `�3rp QL5814�- <br /> StreetAddrestCity <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 ¢tvicing .(CalCode sections 114295 & 114297).,If the use of the commissary is <br /> discontinued, the p hgl�d'((m�4tSotify this office to make the necessary changes. Failure to notify this <br /> office may resul ' pe i r Wic, and penalties. <br /> Si nature of V or Datef <br /> Business Name: <br /> Owner Name: <br /> Site Address: c&Zi7C Z2If d I C C� <br /> Street Address city i <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 ❑ Store frozen food Vehicle wash facilities <br /> (2 or 1 compartments) <br /> ❑Preparation of food E41-lot&cold water for cleaning Toilet&hand wasi ting ❑ Store refrigerated food <br /> ❑Store dry food/supplies Provide potable water Ovennight parking Adequate electrical outlets i <br /> Signature of Commissa O erator Date <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 5 of 6 MFPU APPLICATION <br /> 7/16/2006 . <br />