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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> r f ax <br /> VEHCC-LEINFORMATION, <br /> Vehicle Name (DBA):'\7f4y S C A N G <br /> Address for Vehicle: t^ l.,� ;AcOw-1 S.(;906 <br /> Street Address city <br /> 1) License Plate#: �� �l I"� _ 4) Year: <br /> 2) Vehicle Vin#: 1G3tH.p, K41Z�,31G`1s5�5) Make/Model: ((ncv <br /> 3) State Decal#: 6) Color: <br /> VEHIC E�,OWNERgINFORMATLON *'� t�(' 'r• _� `ir ' <br /> Name:. <br /> Address of Owner: � � l �Y(jl �, S �C��C>Vl _� <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 /> I nature of'qeic(eOperator' Dat / <br /> COMMI <br /> SSARY°INFQRMffION <br /> Business Name: �A c e 't�f rl c 5L) <br /> Owner Name: <br /> Site Address: 20 40 S A-1-1 c r Lvc-- <br /> Street Address city <br /> Phone: )-2 L)1 <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 tensil washing sink Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ff Preparation of food EJ/Hot&cold water for cleaningToil t&hand washing tore refrigerated food <br /> potable water ;Overnight parking 0 Adequate electrical outlets <br /> Store dry food/supplies �PrOvide p <br /> Signat of Commissa O er/ e Date <br /> `Y7 h 2 <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 />