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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 /> Address for Vehicle: <br /> Street Address City, <br /> 1) License Plate#: q 16_ 4) Year: j ��__ <br /> 2) Vehicle Vin #: IL11t p �,K6 AL' 5) Make/Model: ��[-V f1 L <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORmATION <br /> Name: <br /> c` d <br /> Address of Owner: oirQ AVK oilC 7 <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 /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION r <br /> Business Name: ChLI 14 (4 6 I k F&P RrO(6 h4 5LOR <br /> Owner Name: 0-PIM H <br /> Site Address: 2 �V SN Rpt j YV K—TZ) <br /> Street Address city <br /> Phone: (10 1) -CC16T <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 /> Liquid&solid waste disposal ❑ Utensil washing sink <br /> (2 or 3 compartments) PrIstore frozen food ❑Vehicle wash facilities <br /> ❑ Preparation of food PJ Hot&cold water for cleaning ❑'Toilet&hand washing Store refrigerated food <br /> Ivstore dry food/supplies Provide potable water [�Vernight par king-C1�i 042 _E fs! <br /> SUPPLY FOOD AND SERVE E <br /> � " 2%"0 S.AIPPORT WAY ; <br /> CKTON, CA.96206 <br /> Signature of Commissary Owner/Operator Date �. - o. _ con <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 />