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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): <br /> Address for Vehicle: ,./ o AC or--r W,, 'TO LkTrN ` f2 fDb <br /> Street Address city <br /> 1) License Plate#: YA Irl (>k`) 4) Year: /-VZ <br /> 2) Vehicle Vin#: CpL- r`i 331(.1,9q 5) Make/Model: (�� PYu her vtw <br /> 3) State Decal* 6) Color: ltii1��E <br /> VEHICLE OWNER INFORMATION <br /> Name: vhrj <br /> Address of Owner: g rA, Q . ,Ajy Flo,,.l�T y P 2 1.0 <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: .v t <br /> Owner Name: r nc� <br /> Site Address: r ley G . <br /> Street Address city <br /> Phone: (2q " ) 1 y <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 /> �iquid&solid waste disposal fft Utensil washing sink tore frozen foodhicle wash facilities <br /> (2 r 3 compartments) <br /> �paration of food Hot&cold water for cleaning �oilet&hand washingWSJ(re refrigerated food <br /> Store dry food/supplies Provide potable water Overnight parking Adequate electrical outlets <br /> Si nature of Commissa wrier perator 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 6 MFPU APPLICATION <br /> 7/18/2008 <br />