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VERIFIC " 710N OF VEHICLE COI•"ASSAR.Y <br /> Please provide all intwination requested. An incomplete applicatlun may delay approval. <br /> t <br /> ON <br /> Vehicle <br /> - <br /> Vehicle Name (DBA): <br /> Address for Vehicle: _ — e <br /> Street Address City <br /> 1) License Plate#: 4 Year: <br /> 2) Vehicle Vin#: I�y/� �� �l�H73` a ake/Model: <br /> 3) State Decal#: 6) Color: <br /> I VEHICLE Ow-NER_INFORIHAATtON <br /> Name: So r <br /> # 2 a <br /> Address of Owner: c; S S <br /> i Street Address city <br /> i <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> i operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> i 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 /> Torque 1 vl� v��cz r ckrnolre.r_k_ <br /> Signature of Vehicle Operator Date <br /> COMIMISSARY INFORINATIO <br /> Business Name: �' <br /> Owner Name: <br /> Site Address: <br /> -Streett aadrm city <br /> Phone: (29 r711- 1 -7 (--1 / <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 /> Q Liquid&solid waste disposal 0-utensil washing sink(2 or 3 compartments) 0-9-t-ore frozen food 0-A efiicle wash facilities <br /> Q Preparation of food of&cold water for cleaning Toilet&hand washing ®-Store refrigerated food <br /> i <br /> forflood/supplies Provide potable water Q'Ovemight parking Adequate electrical outlets <br /> �% <br /> Si nature of Commissary 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 S of 6 MFPU APPLICATION <br /> 7/18/2008 <br />