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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: ,?6 5 . jo,� U(Af ST 57X <br /> Street Address City <br /> 1) License Plate* 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: CL(,5 r<�)04 <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: SE LI &JA L C 0 �-E <br /> Address of Owner: ;2, c000 S _5ltJ J u W 5T- STKAJ60 9SSLo 6 <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 res It in dermi revoc 'on and penalties. <br /> 3 /°t <br /> Signature of Vehicle OlSerator Date <br /> COMMISSARY INFORMATION <br /> Business Name: �jT/� 6 C — C L E(STEf- <br /> Owner Name: Xk U 11 <br /> Site Address: .S ( o T S VDC� DOU <br /> o, cy -Street Address City <br /> Phone: � ) 2 f F -S q / 4 <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 /> IO/Liquid&solid waste disposal Utensil washing sink store frozen food Vehicle wash facilities <br /> (2 r 3 compartments) <br /> 7d eparation of food Hot&cold water for cleaning E Toilet&hand washing Store refrigerated food <br /> Store dry food/supplies Provide potable water1�Overnight parking D2Adequate electrical outlets <br /> Si a ure of Commissa 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 />