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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): �- WOAgA <br /> Address for Vehicle: 'l LJC) 5. �pAgapuP;T- <br /> StreetrAddress City <br /> 1) License Plate#: rJ r 5 273 4) Year: to) Cl16 <br /> 2) Vehicle Vin#: ((rll3ap 3Z9--7 W 35) Make/Model: CHU y <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: 1.AFLk Seo <br /> Address of Owner: <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 /> -�'V ► <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: CQ r. <br /> Site Address: �L) fa As r ,,u4 (un <br /> Street Address city <br /> Phone: (�� "°) I - 1 q <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 /> Liquid&solid waste disposal D Utensil washing sink tore frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> �.eparation of food Hot&cold water for cleaning [�/Toilet&hand washingS ore refrigerated food <br /> Store dry food/supplies dProvide potable water �/Overnight parking Adequate electrical outlets <br /> Si nature of Commissary <br /> Owner er —o 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 />