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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: G�G ,� cr. G�%�' j G/( car (f <br /> Street Address ' city C-15-•2'0 <br /> 1) License Plate#: / G 4) Year: , <br /> 2) Vehicle Vin #: - 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: n ( cr, 14:- 20 (� <br /> Address o wner: ,� (-, (' 511 <br /> SfreetAddress 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 /> l r' 0 <br /> Si ture of Vehicle O rator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> A lir�P alp <br /> Owner Name: , <br /> Site Address LcFc -(� r_ ) yJy�-�7• <br /> Street Address city <br /> Phone: (1 ) �-c a ���✓ yA <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 /> sink hi <br /> il washing sn <br /> Liquid&solid waste disposal UtensStore frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food dHot&cold water for cleaning L] Toilet&hand washing Store refrigerated food <br /> Store dry food/supplies Provide potable water Overnight 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 />