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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. asw,n.:F ri �4�ttlatup4•' 't'i 'ih „ r�,•+1c .'Yrs r -' 's'f fci`' ` w. /EHICLEINFQ.RMAT;.IQN Vehicle Name (DBA): 'C - Address for Vehicle: Street Address city 1) License Plate#: 8�9��a 4) Year: 2) Vehicle Vin#:��L 3S 7�33o�T'T'�— S 5) Make/Model: 3) State Decal#: 6) Color: VEHICLE OWNER;INFORMATION Name: Address of Owner: 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 office may result in permit revocation and penalties. O Se, Z� Signature of Vehicle O erator Date COMMISSARY INFORMATION; Business Name: '/ Lo Owner Name: Site Address: Street Address city Phone: '-df 51 C'e O L I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: Iquid&solid waste disposal Utensil washing sink ❑ (2 or 3 compartments) e iclStore frozen food e wash facilities reparatio f food Hot&cold w ter for cleaning Z-Teif2t 8�han�d washing ❑ Store refrigerated food 22 tore fo d/supplies rovide potable water vernC' ight parking 2;-Adequate electrical outlets Zo zk4y Signature of Commissary Owner/Operator Date A �� ,� � ,..� �•. ,�:�� . 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 ANN&-