Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEFIICLE INFORfOATICAN - - - <br /> Vehicle Name (DBA): Cali U n'i a <br /> Address for Vehicle: 2 4 4 b <br /> Street Address - - City <br /> 1) License Plate#: N f ! I�.JV 4) Year: 2 <br /> 2) Vehicle Vin #; 26(iEC/71/3Tl/Zof�,g 5) Make/Model: Clb-yli do <br /> 3) State Decal #: _ ` 6) Color: <br /> VEHICLE QWNER INFORMAT12N - -- <br /> Name: <br /> Address of Owner:-2`j, / o, Gtt <br /> Street Address uI <br /> ty <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 114296 & 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 mayresultin'Permit revocation and penalties, <br /> � Z <br /> Signature of Vehicle O eratorDate <br /> -- <br /> COMMISSARY WFOR-- iQfI T <br /> Business Name: Cp{Y1 m S S cif ( a <br /> Owner Name: con roi- e\v\ kfn <br /> Site Address: �. S <br /> Street Address <br /> (2� orcy <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 S compartments) <br /> ❑Preparation of food Hot&cold water for cleaning eaning g ❑ store refrigerated food <br /> ❑ rrrrt��t��Toilet&hand washing Store dry food/supplies Provide potable water �Overnight parking ©Adequate electrical outlets <br /> Sioryatureyo Commissary C nmar/O erato;_ Date <br /> I`IEALTH DEPARTMENT- � yam* ` fi <br /> _ <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-RENS Date <br /> EMD 16-017 5 of n <br /> 7/182008 MFPU APPLICATION <br />