Laserfiche WebLink
VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> _. ., .. - . . ., .... . J <br /> VEHICLE�INFORMATION <br /> Vehicle Name(DBA): E <br /> Address for Vehicle: -7 ?v <br /> Street Address Cdy <br /> 1) License Plate#: 4) Year: . <br /> 2) Vehicle Vin#: �{T/1� / T 1" ���L� 5L) Make%Model: <br /> 3) State Decal* 6) Color: I/ 'Z4 P <br /> FH1G4E - Vlf W R INFOI MAT10N_- <br /> Name: 2 <br /> Address of Ow r: Q v- G G <br /> Street Address Cdy <br /> The mobile food faicifity shall operate out of a commissary and shall report to the commissary at least once each <br /> operating day for Gleaning and servicing (CalCode sections 114296 & 114297). If the use of the commissary is <br /> disco 'nued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office ay;esult in permit revocation and penalties. <br /> �je X, <br /> Si n r of Vehicle O erator Date <br /> GO ISSARY INFORMATIO _ __ - <br /> - -- - <br /> Business Name: f ✓1 ' Li <br /> Owner Name: <br /> Site Address: A <br /> Street Address city <br /> Phone: 2 e / I <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked belowrr:--77�� �,� <br /> Bquid&solid waste disposal �""nsii washing sink ❑Store frozen food ehide wash facilities <br /> -16 (2 or 3 compareronts) <br /> B-15repar err of food of&cold water for deaning oilet&hand washing ❑ Store refrigerated food <br /> for food/suppliesrovide potable water vemight parking uate electrical outlets <br /> `l <br /> i nature of Commissa Owner/0 erator Date _,_.., _,___-_ .— <br /> HEAL7H <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing bek>w. Commissary/food establishment is In <br /> County. <br /> Signature of County REHS Date <br /> EHr1'16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />