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Jy <br /> r " Cl"G:1) VE ICATIOKEOF VEE i[CLE CO�rk4�SS RY <br /> lj3 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: b� ;3 ' ?4'i 4) Year: i Ci 9 °� <br /> 2 Vehicle Vin#: "i-3-' i_2 �I ri I Z �� Make/Model: <br /> 2/ c� , s 3 �s <br /> 3) State Decal#: C 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: /v\ 1\IS �l 'i �' �ilcr Cla 0-15� 1� <br /> Street Address 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 /> Signature of Vehicle Operator Date a <br /> COMMISSARY INFORMATION <br /> Business Name: �� <br /> Ovttner Name: ` t yt d ! <br /> Slte LrdCJrP8c; l`®'l cIII <br /> Street Address city <br /> Phone: (j oq) q:5(4- O CJCJ �' irl <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 ®''Utensil washing sink P\ ❑ Store frozen food L/ehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food Hot&cold water for cleaning• ❑ Toilet&hand washing ❑ Store refrigerated food <br /> ❑ Store dry food/supplies ❑ Provide potable water ❑ Overnight parking ❑Adequate electrical outlets <br /> Sig ature of Commissary Owner/Operator Date <br /> r <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 />