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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. Lq.CC wwl?t sFill y ,O M . T'�1 ,HANI2C �. .. Vehicle Name (DBA): Q �MIS Address for Vehicle: 6 r "r Street Address city 1) License Plate#: 11f q :I I E� 4) Year: 1"I U u 2) Vehicle Vin#: i 4 G 11 F U 1MI Q"Jr� 5) Make/Model: II 3) State Decal#: Cl 6) Color: .asa VEHaIfCaa�Ly, _F ;CCR _0%A Name: EV roi > S b Moil Mum Address of Owner: :Fr(SwL uln ra m Street Address city The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each 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 may result in perm't�evocationvand penalties. {�V lP Signature of Vehicle Operator Date C.OMMISSAFZY �N� NP- Business Business Name: n r Owner Name: Site Address: T50 S C Q S 1 Q Street Address city Phone: (Al) — 1:141 I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: VILi Utensil washing sink Store frozen food Vehicle wash facilities Uld&solid waste disposal (2 r 3 compartments) ❑ Pre aration of food Ho cold water for cleaning Toile hand washing ❑ Store refrigerated food Store dry food/su 'es a potable water Overnight parking Adequate electrical outlets It P /I A8 S ibTfaiure of Co ssa wn rator Date �� A *�� I� ��, «.�311f,�1;1_�> ®>-:..PA�yaX�IYIEIV-ro�� 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 7/18/2008 Aftv�;