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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. Gs - ►RM TIO ` Vehicle Name (DBA): MA M(A Address for Vehicle: 19790 S. bol (A Street Address city 1) License Plate#: 00102- L 4) Year: �JQCI 2) Vehicle Vin#: ��,Q �jZ�� n �O,Q� 5) Make/Model: 3) State Decal#: U►t 6) Color: VEHICLE OWNER INFORMATIO O.11M. Name:._. r W Address of Owner: n isAV1/' R ' I Street Address City The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office may result in permit revocation and penalties. p CAC�-5 6 U-d 1 G Signature of Vehicle Operator Date COMMISSARY_INFORMATI;ON Business Name: f Owner Name: S' or Site Address: 0. Street Address City Phone: 194 I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: [/ Utensil washing sink Liquid&solid waste disposal or s compartments) ❑ Store frozen food Vehicle wash facilities I rr paration of food [ Hot&cold water for cleaning [A/Toilet&hand washing ❑ Store refrigerated food P S re dry food/ s vide po[able water Yovernight parking Adequate electrical outlets i� Si ture of ommi_ . Owner/Op ator Date HEALTH DEPARTMENT- -- If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify current health permit by signing below. Commissary/food establishment is in County. Signature of County REHS Date EHD 16-017 5 of 6 MFPU APPLICATION 7/18/2008