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VERIFICATION OF VE+f1CLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION,, " <br /> Vehicle Name (DBA): (�i �i i) � / (,. <br /> Address for Vehicle: q rj GC LG_ G T <br /> StreetAddress city <br /> 1) License Plate#: J 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <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 /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 1✓f� L'S n'_ T��L S <br /> Owner Name: o*9 L O'i 1/12 <br /> Site Address: 41g6D PA�eJ/'ie 4y S7C— K // S� obi✓ �� s 6 } , <br /> Street Address city <br /> Phone: — d <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 3 compartments) <br /> ❑ Preparation of food ❑ Hot&cold water for cleaning ❑ Toilet&hand washing ❑ Store refrigerated food <br /> ❑ Store dry food/supplies ❑ Provide potable water ❑ Overnight parking ❑Adequate electrical outlets <br /> aw-�ooq� >— e3-/S/- 201 <br /> Signature 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 5 of 6 MFPU APPLICATION <br /> 7118/2008 <br />