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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): 7a(o J El uVroo <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: t��3t �j� 7'j U 0 4) Year: <br /> I <br /> 2) Vehicle Vin#: �FDYfyE�J�l9'��11�4"! 5) Make/Model: For( <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION 2—Q®I �- <br /> Name: C� Via 8 U A rM0 <br /> i Address of Owner: <br /> TA n Firnon v toy Kro V1 <br /> i Street Address City <br /> II The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> 1 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 /> offic may result in permit revocation and penalties. <br /> I iS, 0S <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: foo o r <br /> Site Address: CAl l for I m Z �"o <br /> Street Address city <br /> Phone: (Zoe) q S 19 +S ZS- 20 2-q0' <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 /> Liquid&solid waste disposal Utensil washing sink ❑or 3 compartments) Store frozen food Vehicle wash facilities <br /> reparation of food Hot&cold water for cleaning [Z/Toilet&hand washing ❑ Store refrigerated food <br /> dry food/sup lies ide potable water 10/ovemight parking Adequate electrical outlets <br /> Si ure of Co sa w r or Date <br /> HEALTH DEPARTMENT <br /> If the commissarylfood 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 />