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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): Address for Vehicle: Muffn Street Address City 1) License Plate#: �Q�{"a5 C) 4) Year: 2) Vehicle Vin#: G �jJr�}r1� I I O U 5) Make/Model: V 3) State Decal#: 6) Color: VEHICLE OWNER INFORMATION Name: amixmutro uA is - Address of Owner: S. NISO 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. L45 L0-5 2-01 vl l Signature of Vehicle Operator Date COMMISSARY INFORMATION Business Name: GA I I 10.! h fn U rtrl n N oS Owner Name: W 1A c Site Address: 1410 S COl h I V T- Street Address �� I � �'O� city Phone: ( q-9 03 � I,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: Li uid&solid waste disposal ;Hgt'& �Utnsil washing sink ❑Store frozen food Vehicle wash facilities q o3 compartments) tP eparation of food cold water for cleaning �flet&hand washing ❑ Store refrigerated food Provide potable water �vemight parking �Adequate electrical outlets Store foo supplies 1 Signature of Commissa owner/Operator 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