Laserfiche WebLink
7() <br />5-3-c) <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): <br />Address for Vehicle: <br />Y.ai <br /> <br />CsJior: <br />License Plate #: <br />Vehicle Vin #: <br />State Decal #: <br />Street Address City <br />- <br />VEHIC...E OWNER INFORMATION <br />qame: 121 c( • <br />/-‘ddres:- of Owner: i)fr <br />Street Address City /- <br />)67-1<__ — <br />The mobile food facility shall operate out of a commis ri 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 />Signature of Vehicle Operator Date <br />VEMFICATION OF VEMCLE COMMoSSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />COMMISSARY INFORMATION! <br />Business Name: C(-) De ci I Ls 8(u,4 <br />Owner Name: s ?( , <br />Site Address: `-(6"- c2(Li <br />Street Address City <br />Phone: ( <br />I, the corrInissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commiss lry as checked below: <br />ET <br />//// <br />,./-- ,...-- <br />Utensil washing sink IV) Liquid & solid waste disposal E Storezfrozen food Z,-Vehicle wash facilities <br />/ (2 ori3-compartments) <br />,/ _/. _.// <br />I VI' Prep ration of food <br />— <br />I-10t & cold water for cleaning i,Toilet rz.& hand washing Store frigerated food <br />i rq Store dry food/su p -Provide potable water El Overnight parking <br />7 _ 7_____ <br />i 'at • <br />If the commissary/food establishment is outside San Joaquin ..ourtty, the local health jurisdiction must verify <br />current health permit by signing below. Commissary/food eQth.)lic-1:.n nt is in <br />County. <br />Signature of of County REHS <br /> <br />Date <br />dequate electrical outlets <br />l-3ignature of Commissary Owner/Operator <br />-tEALTH DEPARTMENT <br />END 16-017 <br />7/18/2008 <br />5 of 6 <br />_ <br />MFPU APPLICATION