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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): f r-"�-a•1 <br /> Address for Vehicle: <br /> Street Address J city <br /> 1) License Plate#: 4) Year: <br /> 2 Vehicle Vin#: - Make/Model: y t (' <br /> 3) Slate Decal #: 6) Color: <br /> 'r-111CLE niarm= At— <br /> fA1 CllR BAATICS f�I �� <br /> Name: <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 /> 45 <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: 1i I✓l j" <br /> Site Address: S. IA1 I1'LIIa 01/i, <br /> Street Address Citty <br /> Phone: <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 /> Utensil washing sink �✓ Store frozen food Q Vehicle wash facilities ... <br /> Liquid&solid waste disposal (2 ora compartments) <br /> Hot&cold water or cleaning 12/Toilet&hand washing ✓ Store_refrigerated food <br /> fli = j <br /> Preparation of food � - -- � <br /> tore dry food/supplies Q�Provide potable water Overnight parking Adequate electrical outlets <br /> Di <br /> Signature of ommissar Owner/Operator 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 sianing below. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br /> 5 of 6 <br /> EHD 16-017 MFPU APPLICATION <br /> 7/18/2008 <br />