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VERIFICARON OF VEHICLE CO ISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): �� i� -. Address for Vehicle: Street Address City Zip Code 1) License Plate#: 14C- "7C% 4) Year: 1 0 2) Vehicle Vin#:11_1 5) Make/Model: 67 /qtr C__3) State Decal #: 1 6) Color: VEHICLE'OWNER INFORMATION Name: L2 !'ly Address of Owner: c • I -y" Street Address City Zip Code The above-mentioned vehicle shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing [CURFFL 144265 & 114287]. If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office could result in permit revocation and penalties. 1 a 47 dry Signature of Vehicle Operator Date COMMISSARY INFORMATION. Business Name: Cys v n t, Owner Name: Site Address: 0 Street Address U City Zip Code Phone: I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: Liquid&Solid waste disposal Utensil washing sink Store Frozen FoodProvide ice (2 or 3 compartments) 1p Preparation of Food Electrical Hook-up �Toilet&Hand washing �Vehicle Wash Facilities Store Dry Food/Supplies E�rovide potable water 0/ Overnight Parking Store Refrigerated Food �'A -/ 7-� ignat e of Comm' sa Owner/Operator Date HEAL+H DEPARTMENT, u, . .'_ If the commissary/Food establishment is outside San Joaquin County,the local health jurisdiction shall verify current health permit by signing below. Food establishment/commissary is in County. Signature of County R.E.H.S. Date EHD 16-01-017 Page 5 of 6 MFPU APPLICATION 6/21/2004