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RECEIVED <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay apprFEB 19 2019 <br /> F e;, Ei iiCLE I` �- 3R 'i'ie� RON NI E N TA L H .' LTH <br /> 11�t RT <br /> Vehicle Name DBA <br /> a <br /> Address for Vehicle: � ' <br /> -r, <br /> Street Address Clty <br /> 'i) License Plate;6: Y10 // .S 4>L) 4) Year: l 7 <br /> 22) Vehicle Vin#: .� 5) Make/Model: <br /> 3) State Decal#: G) Calor: <br /> NFORMATION <br /> 1 <br /> Name: <br /> V <br /> Address of Owner: <br /> Street Address i City <br /> he 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 (CalCoda sections 194295 & 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 To-suit iso permit revocation and penaities. <br /> I <br /> Signature of Vehicle 0 e afar - Date <br /> ,-3IAMlSSA-P'Y INN ORMA IOC <br /> Business Mame: <br /> Owner(dame: c , <br /> Site Address: 'q 00 K tin i - �' 1 c�` i <br /> 01 i <br /> StraetAddress - —T .• �,; city <br /> Phone: (Z{;,1,) [,.t (J <br /> I ,ti to comrnissanj owner,can and will provide the necessary facilities for the above mentioned)vehicle at mv <br /> 3 co irnissany as checked below: <br /> d <br /> � Utensil washing sinlc c s <br /> • ( Liquid&solid waste disposal ❑Store frozen food 3� Vehicle wash facilities <br /> (2 or3 compartments) <br /> ❑ Preparation of food [ Not&cold water for cleaning 0 Toilet&hand washing 0 Store refrigerated food <br /> ❑StgFe dr,,r foodlsupplie��//-"' Provide potable water ?a Overnight parking E Adequate elecloical outlets <br /> Signature of Co missanj Owner/Ope or '-7777"' Date <br /> -1,21AIT ii EDEPARTMI N- 1 <br /> Jf the cornmissandfood establishment is outside San,Joaquin County,the local health jurisdiction must verify <br /> c+�3 s ei3t heaith permit by slgning beloulf. Cont misseryffood establishment is in <br /> i <br /> Signature of County RENS Date <br /> i <br /> EHE 16-017 5 of 6 MFPU APPLICATION <br /> 7!18!2008 <br />