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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> ri+ .. <br /> !... ;,. ,- .,,., ,„.. _..r..:,_.. ede"kY,@.' „`:''-w. 'e•. �!'�1im .+7wr, .✓+ L <br /> u <br /> a <br /> Vehicle Name(DBA): — ;--D, <br /> Address for Vehicle: -� �; <br /> street Address Cify <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin#: C RL 3S - 3 -3'0 8 5-0 5) Make/Model <br /> 3) State Decal#: 6) Color: <br /> NOW <br /> Name: <br /> Address of Ow er: <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 may result in permit revocation and penalties. <br /> Skat re of Vehicle O ator Date <br /> Dt]MMi3SA1tY INFO <br /> �. = ° a <br /> ,.... 4 :_ .... <br /> Business Name: � <br /> Owner Name: <br /> Site Address: <br /> street address city <br /> Phone: o-� <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 /> _iquid&solid waste disposalil washing sink <br /> tg) <br /> or 3 c <br /> (2 or 3 ompartrnents ❑ Store frozen food e-h-i e wash facilities <br /> reparatio food U'Vorl cold water for cleaning oilet&hand washing ❑ Store refrigerated food <br /> L dry foodJs les rovide potable water L vemight parking �duate electrical outlets <br /> Signature of Commissa Owner/O erator Date <br /> HF-ALTH DEPARTmeNT . <br /> ff the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissaryffood establishment is In <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 711812008 <br />