Food Truck Application

Name of Legal Owner:*

First NameLast Name
Is the Legal Owner a:*
If other, Please Specify:*
Provide the name of all individuals comprising legal ownership and their mailing addresses*
Certified Food Safety Manager’s Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Name of Person Applying for Permit*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to business*

Days, Hours, and Location of Operation:
Ex) M-F 9 a.m. - 5 p.m. @ Main St., Sat-Sun 8 a.m. - 12 p.m. @ Davis Parking Lot
Public Water Source*
Wastewater Disposal*
Commissary?*

YesNo
If yes, location of commissary*
Vehicle License Plate*
Where will utensils be cleaned?*

I hereby certify to the best of my knowledge, the foregoing information is correct. I agree to abide by TriCounty Health Department’s food establishment sanitation rules. I understand that this permit is revocable for non-compliance with health
department rules and regulations. The health department will be allowed inspection access to the establishment and establishment records. I understand that this permit is non-transferable.
Signature*

Clear
Should be Empty: