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VIERIFICATION OF VEHICLE COM <br /> P.RLSce�v <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA) j�' � <br /> Address for Vehicle:-2,M _ &T, <br /> Street Address �- City <br /> 1) License Plate#: b6�)2J�p V 4) Year: NA <br /> 2) Vehicle Vin #: GPM �X44 fl 5) Make/Model: �►I�Y��� U� <br /> 3) State Decal #: 6) Color: <br /> 1/EHICLLE�O,WNER INFORMATION <br /> Name: f'G I Ii k Ai �� - <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 /> / 1'a�I'MO. R,,".�(- -2 �2�� /s- <br /> Signature <br /> S <br /> Si nature of Vehicle Operator Date <br /> COMMISSARY,INFORMATION . `(. <br /> Business Name: <br /> Owner Nam( irr? <br /> Site Address: 44c <br /> �J Street Address t _Ctty <br /> Phone: (:10 C11) <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 /> quid&solid waste disposal ❑ Utensil washing sink 0/Store frozen foodVehicle wash facilities <br /> or 3 compartments) <br /> ❑ Preparation of food Hot&cold water for cleaning it t& hand washing �/Slo refrigerated food <br /> Store dry food/supplies Provide potable water Overnight parking Adequate electrical outlets <br /> Si nature of Commissar 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 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 />