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VER�MCAT�ON OF VEHUE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION {� f�-•� � (� <br /> Vehicle fume(DBA): <br /> Address for Vehicle: <br /> ) <br /> Street Address City <br /> 1) License Plate#: �/'C� �93� �} Year: <br /> 2) Vehicle Vin 5) Make/Model: 0 <br /> 3) State Decal*. 6) Color: ' <br /> ,P- 1. <br /> VEHiCLE qWNER-INFORMATION7. <br /> Name: a <br /> Address of Owner: a G ✓a� <br /> Street Address <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 /> i discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> ,�� ay ?esult in permit revocation and penalties. <br /> .� Yt'I <br /> Signature of Vehicle Operator Date <br /> -:DflllMISSARY INFORMATION <br /> } Business Name: <br /> Owner Mame: 1 1 �— <br /> r- � G.��i <br /> Site Address: N00 I"1T d �' `6 CA <br /> Street Address --� —� city ^' 4 <br /> Phone: (ZC(yA} <br /> i i,the cornrnissanj owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> r » Utensil washing sink c <br /> Liquid solid waste disposal (2 or compartmerft) Store frozen food ) Vehicle wash facilities <br /> i <br /> ❑ Preparation of food Rot- <br /> &cold water for cleaning 0 Toilet&hand washing Store refrigerated food <br /> ❑ Store food/supplies Provide potable water Overnight parking Adequate electrical outlets <br /> i Signature of Commissary Ownerl0 erato Date <br /> 1E-.L7H DEPARTMENT <br /> lIf the commissary/food establishment:is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissarylfood establishment is in <br /> � . <br /> t ' <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 711812008 <br />