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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): '7(A,(.0c� tf Address for Vehicle: L, ZcW, MC-'-1� Street Address city 1) License Plate#: v.w o-z-(28 6 4) Year: i q 2) Vehicle Vin #: i&)G 141)J L-^)(C-43—L Z5) Make/Model: G ff e-V y 3) State Decal#: 6) Color: W�, VEHICLE OWNER INFORMATION Name: -aHIf- I � �''i`� Address of Owner: 'apt >lvd f �� c, �f j 7 Street Address City The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office m It in permit revocation and penalties. Signature of Vehicle Operator Date COMMISSARY INFORMATION Business Name: Owner Name: Site Address: 244L)L) r-pu14 mac. Street Address City Phone: (el-o ) I I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: N'Kiquid&solid waste disposal El Utensil washing sinktore frozen food ehicle wash facilities (2 or 3 compartments) reparation of food Hot&cold water for cleaning El Toilet&hand washing lwl Store refrigerated food Store dry food/supplies Provide potable water Overnight parking Adequate electrical outlets Signa ure of Commissa wner/Operator Date HEALTH DEPARTMENT If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify current health permit by signing below. Commissary/food establishment is in County. Signature of County REHS Date EHD 16-017 5 of 6 MFPU APPLICATION 7/18/2008