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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> >"�v ,k�t. .✓.tl;+.m, itisau. .m..4 t.,r,. w.. Asa: w,. ;~2'..11:`.: <br /> Vehicle Name (DBA): o <br /> Address for Vehicle: <br /> S reet Address <br /> 1) License Plate#: t=��J 9„C 4) Ye <br /> 2) Vehicle Vin#: 1 *AW/lodel: <br /> 3) State Decal#: 6) Color: <br /> �� �.. ,d-� <br /> VEHICLE®W EN FINFORNIP►�TIO � fixw.. x� :in , ..w G."., x <br /> tV , <br /> Name: <br /> Address of Owner: <br /> St eet Ad ress �ItY <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 /> T <br /> ice may result in permit revocation and penalties. <br /> a I-1 R ((1 ur'C�9^ ' �,Lo� <br /> Signature of Vehicle Operator Date <br /> CL137!►IIIS, ,,L,RY, INF,,�ORMA�TION � 4 � `'.� "• ' �,�, <br /> Business Name: <br /> Owner Name: <br /> Site Address: ' <br /> —Street Addres city <br /> Phone: (pZ Q <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 /> Utensil washing sink Store frozen food ehicle wash facilities <br /> Iquid&solid waste disposal (2 or 3 compartments) <br /> �;� reparation of ood of&cold water for cleaning oilet&hand washing ❑ Store refrigerated food <br /> tore food/suppliesrovide potable water vernight parking Adequate electrical outlets <br /> � s <br /> i nature of <br /> Commissary Owner/Operator Date <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 quftk <br />