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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): , Q <br /> Address for Vehicle: 97?0 S. (MMOKNO 1 1 r4 <br /> Street Address 'n city <br /> 1) License Plate#: _'I Vl`4 lX 1O 4) Year: <br /> 2) Vehicle Vin#: �T, ?� M `M1 5CGOIIAake/Model G <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owney 2. #� L � 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 /> officey result in permit revocation and penalties. <br /> 7a4,1,1 <br /> SignJOV6 of Vehicle Ope ator Date <br /> COM ISSARY INFORMATION <br /> Business Name: I, amIVl M N <br /> Owner Name: r <br /> Site Address: <br /> o s �� f r�I sfi. Oc Qr► <br /> Street Address city <br /> Phone: (A) fi I U91114: <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 /> �i�{uid&solid waste disposal Utensil washing sink ❑ Store frozen food Vehicle wash facilities <br /> // (2 or 3 compahments) <br /> Preparation of food Hot&cold water for cleaning �''Toilet&hand washing ❑ Store refrigerated food <br /> [�/Sto f d/supplies Provide potable j r Overnight parking E 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 hrFPU APPLICATION <br /> 7118/2008 <br />