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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): M Q <br /> Address for Vehicle: 9170 S. <br /> Street Address City <br /> 1) License Plate#: -`W4 LQ10 �1 4) Year: <br /> 2) Vehicle vin#: I C T� ?�aMXM�5050111ake/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: LHE UNIUA <br /> Address of Owner: rj E-. 2. � L C/i 1 S <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 y result in permit revocation and penalties. <br /> Sign of Vehicle Ope ator Date <br /> COM ISSARY INFORMATION <br /> Business Name: ` Q Yl�V 1 C <br /> Owner Name: r ,Pj ros r y <br /> Site Address: Tu. L(/� 10❑ ,9i-• Q C Q <br /> Street Address �1 I I city <br /> Phone: (XI) � �a �� 1` ��"� u114 <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 /> �Li uid&solid waste disposal u Utensil washing sink ❑ Store frozen food F1 Vehicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food Hot cold water for cleaning 'Toilet&hand washing ❑ Store refrigerated food <br /> ©'Sto f d/supplies Provide potable w r W Overnight parking Adequate electrical outlets <br /> Signature of Commissary 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 /> EFID 16-017 5 of 6 MFPU APPLICATION <br /> 7/1812008 `� <br />