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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#: //`Ol (,� � 4) Year: n� <br /> 2) Vehicle Vin #: 5)�� 5) Make/Model: C <br /> 3) State Decal #: 6) Color: (.(/ <br /> VEHICLE OWNER INFORMATION <br /> Name: e <br /> Address of Owner: <br /> Street Address ci y <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, a permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office may re It in permit revocation and penalties. <br /> f// Z <br /> Si nature of Vehicle Operator Date <br /> COMMISSARY INFORMATIO <br /> Business Name: <br /> Owner Name: <br /> Site Address: <br /> Street ddress City <br /> Phone: (a l� <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 tensil washing sink ❑ Store frozen food Vehicle wash facilities , <br /> (2 or 3 compartments) <br /> Preparation of food !❑'Hot&cold water for cleaning oilet&hand washing ❑ store refrigerated food <br /> ore ryof od/suppliesProvide potable water O'6ver In ght parking O'Addequ tae electrical outlets <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 />