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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): UUZ, /) f Ve'r L — <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate#: _T F S q1 7� 4) Year: <br /> 2) Vehicle vin #: I 6T Kq ' 15_Sk) Make/Model: 6AI C <br /> 3) State Decal 3#: 6) Calor: <br /> VEHICLE OWNER INFORMATION <br /> Name: V Ve-v� S <br /> Address of Owner: G�,�U� <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�.I'r r arc_ Cae_d', -L.Q 5Q Doti --__---- <br /> Owner Name: _t 11 r" sc <br /> Site Address: y S A�pey" i �`� _S�C-� � GA_ q�� ' <br /> Street Address i T— City <br /> Phone: (ZGy) Z Lj <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> washing Liquid&solid waste disposal /Utensilg sink ore frozen food Chicle wash facilities <br /> (2 or 3 compartments) <br /> �--t�r paration pf food of&cold water for cleaning Toilet&hand washing �+ re refrigerated food <br /> Store dry food/supplies Provide potable water � de + <br /> � U Overnight parking /Adequate e;cctrical outlets <br /> Signature of Commissary wner/ er 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 3 R;IFPU APPLICATION <br /> 7/13/2008 <br />