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0 <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): / 1�� <br /> Address for Vehicle: Z V <br /> wcs <br /> Street Address _ City <br /> 1) License Plate#: _713345_ Z9V 4) Year: <br /> 2) Vehicle Vin #: I- tJ4;?3z �( b:3S�� �� Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: "� �.l1 G'k-cc.1t VU <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 /> offic,T may re.$ult in permit r natio Wand penalties. <br /> �l <br /> Si nature of Vehicle`Sperator T— D to <br /> COMMISSARY INFORMATION / <br /> Business Name: /Il 0y,�L�� lC r c I <br /> Owner Name: j� VC���� 3u r <br /> Site Address: y u `� Q"tf t�<�- v�,►.. k-)c <br /> Street Address City <br /> Phone: (�Lj ) ­Z_-�:_ �/ <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 /> EqXquid&solid waste disposal Steehicle Utensil washing sink ore frozen food wash facilities <br /> Xot <br /> compartments) <br /> S Pre aration of food cold water for cleaningoilet&hand washingS re refrigerated food <br /> Store dry food/supplies Provide potable water vernight parking Adequate electrical outlets <br /> Si re of Commissary Ow er perator 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 /> 7/18/2008 <br />