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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHLGLE.INFORMATION Vehicle Name (DBA): Add.,ess for Vehicle: S Street Address city 1) License Plate#: 4) Year: 2-0�' 2) Vehicle Vin#: �5) Make/Model: 3) State Decal #: 6) Color: Nr(/� VEHICLE OWNER`INFORMATION Name: 1 . i V" I D ✓ Address of Owner: -/ SVo"'ffl Street Address City 41 The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each 1 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 mW result in permit revocation and penalties. v r Signature of Vehicle O eratcr Date COMMISSARY INFORMATION Business Name: Owner Name: 0 r ,(mm I I o Site Address: 6/ f J' i1 (1 d� Street Address city Phone: (ZO I) ZJ I— g1-4 I 1,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: '.Liquid&solid waste disposal Utensil washing sink ❑ Store frozen food 10 Vehicle wash facilities (2 gr`3 compartments) Preparation of food Hot'&cold water for cleaning ❑Toilet&hand washing El store refrigerated food i Stole d�food/sur its /Provide potable water ❑6vemight parking ❑Adequate electrical outlets Si ature of C6mrnlssa. Owner/Operat6r 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 7/1812008