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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): TCt,CcsS 2 L C <br /> Address for Vehicle: 7 , ' <br /> Street Address itY <br /> 1) License Plate#: w a�50 g t4,()J Year: Iq gs- <br /> 2) Vehicle Vin #: Make/Model: M L <br /> 3) State Decal #: 6) Color: <br /> o � <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> 17110 C-76C 14 t YJ o -7- <br /> Address of Owner: j <br /> Street Ad ress 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 /> liq Ile <br /> – \ J/10�1 4 11� ��)0/'0::5;11117 — <br /> SighbIfur6 of Vehic e Operator Date <br /> COMMISSARY INFORM TIO <br /> Business Name: L <br /> Owner Name: <br /> Site Address: <br /> Street Address city <br /> Phone: ( H2-51-9) `J <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 0�1ensil washing sink ❑ Store frozen food g1le-hi'cle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food of&cold water for cleaningoilet&hand washing ❑ Store refri erated food <br /> �eorfo /su li s �rovidetable water [ �ver�ni ht arkin Adequate electrical outlets <br /> PP �i' �4-n 9 parking <br /> 1 f L <br /> Signature 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 /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />