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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> ,fiORM <br /> -W;-R;;4-I-0- <br /> Me <br /> Vehicle Name (DBA)': <br /> Address for Vehicle: <br /> cc) lz�( 3 <br /> Street Address i y <br /> 1) License Plate#: (/V' 4) Year: <br /> 2) Vehicle Vin#:/&-9kJP3ZR6 Lf-,-z, <br /> f4e5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE,OW 'M"A'T- 1: <br /> _M! F <br /> Name: dV-0 A,'-';'-/'0 zv <br /> -2 <br /> Address of Owner: �7 <br /> (0-4? <br /> 2 <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 re It in per it revoc ion and penalties. <br /> Si nature of Vehicle Opef9for Date <br /> Business Name: X�k ,s4 <br /> Owner Name: <br /> 73 <21 <br /> Site Address: (D <br /> Street Address city ol <br /> Phone: L:�?Zz 427--Z- ;g;�j 4;� Z� 17zl <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> I---- <br /> YLiquid&solid waste disposal Utensil washing sink(2 <br /> frozen food ehicle wash facilities <br /> (2 3 compartments) <br /> repay tion of food Hot 9 <br /> ot) <br /> F -/H cold water for cleaning �oilet&4,145nd washing ❑ store refrigerated food <br /> r <br /> ��00�L l: <br /> to d oo upplies Provide potable ater Overnight parking [Ledequate electrical outlets <br /> 1 s <br /> gi <br /> ianatu re of Commi SSarV Owner/operator Date <br /> 5a <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 />