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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: 9Q11 L1 j SSD 5 <br /> Street Address City <br /> 1) License Plate#: 4) Year: 2 0 "7 <br /> 2) Vehicle Vin#: 4/m,/9(f 1 U2C 3 N50J - 5) Make/Model: <br /> 30i$ <br /> 3) State Decal #: I "q- 6) Color: G z <br /> VEHICLE OWNER INFORMATION <br /> Name: 7DKA2AN w� <br /> Address of Owner: 5 w,'it,�rn oS5 i31�� b c�k�dr�l <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 perr�n+ Ider must notify this office to make the necessary changes. Failure to notify this <br /> office may resU inp revocation and penalties. <br /> �— (J/n/201 r <br /> Si nature/pf,Veti cle Operator) Date ' <br /> COMMIS AR-�_INFORMA�N <br /> BusinesslfName: //,N� <br /> Owner Name: <br /> Site Address: &4SSU S <br /> St eet Address city <br /> Phone: (;O C) _ S 70 <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 [A Utensil washing sink <br /> (2 or 3 compartments) ❑ Store frozen food ® Vehicle wash facilities <br /> ❑ Preparation of food 9-Hot&cold water for cleaning ® Toilet&hand washing ❑ Store refrigerated food <br /> ❑ Stofe dry food/supplies Provide potable water Overnight parking ©Adequate electrical outlets <br /> Signature of Commis-o4a Owner/Opera Date <br /> HEALTH DEPAR MENT <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 />