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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): 000 'kms 1-1 Address for Vehicle: AIA VKLLAN ( /( treet Addressity -, 1) License Plate#: �WS o Ql 2 4) Year: �oc` 2) Vehicle Vin#: C'j\X'1 5) Make/Model: 3) State Decal #: �bag� 6) Color: VEHICLE OWNER INFORMATION Name: Address of Owner: 5930N 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 offi a re It in permit revocation and penalties. �� Si nature of Vehicle Operator Date COMMISSARY INFORMATION Business Name: N\&�'u Owner Name: Site Address: Street Address city Phone: ('ZO ) 4p - 3 I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: ❑ Liquid&solid waste disposal ❑ Utensil washing sink (2 or 3 compartments) ❑ Store frozen food ❑ Vehicle wash facilities ❑ Preparation of food ❑ Hot&cold water for cleaning ❑Toilet&hand washing ❑ Store refrigerated food ❑ S dry food/supplies ❑ Provide potable water ❑ Overnight parking ❑Adequate electrical outlets c SI nature of Commiss Owner/O era a✓ 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