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IVIERIFICATION OF VENCILE COMMISSARY <br />Please provide ail !r?O'm8tl^.•Cl rSgTl9sted ^-,) incomQiete application rrlav delay approval. <br />VEHICLE INFORMATION—___— <br />Vehicle Name (DSA): j= 01`�j--� <br />Address for Vehicle: 21�--- <br />Street Address <br />Cibr --- <br />1) License Plate #: �� 3 � _ 4) 'Year: <br />2) Vehicle Vin : �� � �Sp�� ake/Model: <br />—%123:' <br />3) State Decal #: <br />_�k%A- <br />VEHICLE OWNER INFORMATION <br />Name: <br />Address of O=r —L�� v _�r -- <br />Street dress �.le�-- �— <br />City <br />The mobile food facility shelf 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). <br />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 />_ <br />COMMISSARY INFORMATION <br />Business Name: <br /><<����.--C <br />---- <br />Owner Name: <br />�► V�-v��C,/� <br />-- <br />Site address: 2—(� (jJ S, —rP; ,1- <br />Street <br />Z�,^ <br />=1— <br />Address <br />cit, <br />Phone: (2rcl) 2 -; <br />1, the commissary owner; can and will provide the ;,s:cessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />LiMuid & solid waste disposal � ensi; sJas�,i: c s:nk <br />S;Gfc <br />TfC_8 ?oG;, <br />(2 or a compartments) ! <br />Preparation of food �Hct I <br />E,�hicie vdash facilities <br />cold :"3?er fpr :- 1 Ino e_ - —c . ? hand washing <br />I J�gtGre refrigerated food <br />I Store dry, foo�-/suppiie5 <br />F •1_ fir''?_.;�? , t. =rt ,',nrr; - <br />IAdequate ele-r, aj c -r tIet_- <br />1J JCS%� <br />Si nG-­,-e cf Commissary Ovrner/Oper=for Date <br />HEALTH DEPARTMENT <br />"Ile 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 I <br />County- <br />' <br />I <br />Signature of County RENS Date <br />EHD 16-01? <br />