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0 0 <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): Cq 2oA <br /> Address for Vehicle: G�G C►%. ���' �. C!� cfy C� <br /> Street Address city C?5-"21 0 <br /> � � <br /> 1) License Plate#: WF.,709C 4) Year: O' <br /> 2) Vehicle Vin #: 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: ,�Y'lHade47j 0 " <br /> Address o wner: �' (� `,✓� J� /•(,fJ'j n _ <br /> Street Add ss 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 /> SibWture of Vehicle O rator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: 19JR y-/ 79 <br /> Street Address city <br /> Phone: ( ) <- �-�� y�� <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 /> k i <br /> hi <br /> washing sink Liquid&solid waste disposal UtensilStore frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food [ Hot&cold water for cleaning 9 Toilet&hand washing Store refrigerated food <br /> © Store dry food/supplies Provide potable water dOvernight parking IvAdequate electrical outlets <br /> Signature of Commiss 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 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />