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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): <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate* 4) Year: 1 <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of OwnI�JL ( Z 9 <br /> treet Adaieh 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 /> /�% h,/l"/Z/_� <br /> Si nature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: n Y� <br /> Owner Name: <br /> Site Address: ' 7 riY7,YL <br /> �v( Street Address / Q City <br /> Phone: - <br /> a - <br /> f,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> fir <br /> Liquid&solid waste disposal I-1 Utensil washing sink Q <br /> (2 or 3 compartments) Store frozen food EJ Vehicle wash facilities <br /> P 11 reparation of food Hot&cold water for cleaning "TOt&hand washing � Store refrigerated food <br /> DS re'dryfood/supplies 111Provide potable water Overnight parking 0 Adequate electrical out!ets <br /> Sib nature 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 />