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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> 22, <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate#: j 4) Year: <br /> 2) Vehicle Vin#: /(T3oSnJ35a3�` ) Make/Model: <br /> 3) State Decal#: 6) Color: lZ <br /> '+ '4`'e'F,� ia3.�,e.xti' 1_ <br /> VEHI LE;OIAINERINFORM�4T O�N N <br /> � .. <br /> Name: <br /> Address of Owner: 172,4 6m18•e•)cyst L— LuY 5 o c <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 /> PIQLq UIC I V(r` '�2////9 <br /> Signature of Vehicle O erator Date <br /> COMIVIISSY INF�RMAT •'N .a�" ,�,.,� 4 ¢ "�' <br /> Business Name: (� 11 ' �� >o�Z C C tx s <br /> Owner Name: <br /> Site Address: 3v /Z- <br /> Street <br /> GStreet AdcTress city <br /> Phone: (z to © 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 /> Utensil washing sink F-1storefrozen food � ehicle wash facilities <br /> iquid&solid waste disposal (y or 3 compartments) <br /> Ei4rep on of food Hot&c water for cleaning Toilet&hand washing Store refrigerated food <br /> Store ood/supplies Provide potable water vernight parking [ 'Adequate electrical outlets <br /> Siijnatureof Commissa I Owner/Operator Date <br /> �HEAL.T D.EPARf-MEN� -� �� �� �� _°u •"'��`' <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 />