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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 - - ' <br /> ( ) <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate #: �/V��l S i oZU 4) Year: <br /> 2) Vehicle Vin #: y��C�.�/`� �3/�C Sf i!}�) Make/Model: 7_ <br /> 3) State Decal #: tel` 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: <br /> Street Address cit, <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 /> Sie of Vehicle Operator Dafe <br /> CbMMISSA'�RY INFORMATIQN N <br /> Business Name: <br /> Owner Name: �. y '1�I�5 t I li✓ �Z� <br /> Site Address: <br /> Street Address city <br /> Phone: ( � ) � 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 /> 1:1Utensil washing sink X-1 - ---- — - <br /> quid&solid waste disposal g Q S ore frozen food . ;, �/e Icle•w s -.fac�tit'eS�- - f` �- <br /> (z or 3 compartments) _�1—� l�I Ih/� ��I E i`.:Nv I <br /> Preparation of food �ot&cold water for cleaning Flet&hand washingSu *Xore I:eIQPa 28SE(-MICE <br /> 440 S.AIRPORT WAYStore dry food/supplies 13/provide potable water 80 <br /> Overnight parking; Af� OTgG�SOle�s <br /> Signature of Commissar Owner/Q erator Date <br /> HEALTH DEPARTMENT' <br /> If the commissary/food establishment is-auttid San',lpaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commis-5 /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 />