Laserfiche WebLink
VERIFICATION OF OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />- Vehicle Name (DBA): - -t....-fri j G---c ) <br />Address for for Vehicle: 6 -2 0 ._-) ,..---;‘, 4-4. Le, C. , q ,5 2 sv <br />Street Address City <br />License Plate #: 3 761 ,i5 3. s 4) Year: / ct 6 7 <br />Vehicle Vin #: ic:sc_i-i i.),3 h4 (4 3303 /5. Make/Model: C i-ie y <br />State Decal #: 6) Color: <br />VEHICLE OWNER OWNER INFORMATION <br />Name: 19 le /60 d kJ a--0 0 cv <br />Address of Owner: <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 />'Z/-e4•' ..„.47----e-----, /..2 — /1— / 7 <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: ? 1-eG(-__ C: 6 evi n , ,1,/ Y <br />Owner Name: n- / se/ t-4-*/ J vL• ei L. - ------ <br />Site Address: 6 .2 0 J.- ,5 o(l—e ek, ,L6)Aq 3 <br />Street Address City <br />Phone: (--x,e, ) 7 / 2 6 •-- 5 7 <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 />1 Liquid & solid waste disposal Utensil washing sink I 1 Store frozen food I I Vehicle wash facilities <br />(2 or 3 compartments) <br /> Preparation of food FT-Hot & cold water for cleaning 7 Toilet & hand washing Ti Store refrigerated food <br />t, '" Store dry food/supplies 1 - I Provide potable water 7-Overnight parking Adequate electrical outlets <br />-• ,->"----!--- -----7 (1--h.7,—, / — 8 — / 7 <br />Signatifre of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <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 <br /> 5 of 6 <br /> <br />MFPU APPLICATION <br />7/18/2008