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VERIFICATION OF VEHICLE COMMISSA` �' <br /> �.� <br /> Please provide all information requested. An incomplete application may delay approval.;, <br /> VEHICLE INFORMATION Af <br /> HLA <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: 4 4b �" _L 4) Year: <br /> 2) Vehicle Vin #: /GL r>l 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> s s_.r nva_� v��rsr_r� Iry vr�nu�r rvr• �- <br /> Address of Own4:: 7// 1-1) <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 (CaiCode sections ii4295 & ii4297). 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 result in permit revocation and penalties. <br /> -/7 <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: ', . . �, C�'t' <br /> Owner Name: —�. � <br /> r . 1- r <br /> Site Address: N00 E. K A•N 0C �� �7�' �`. �J ? n <br /> II'' Street Address +� 1 city <br /> V <br /> Phone: (2(,LJ) kV�� L"� 51 <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 Utensil washing sink u Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) I <br /> ❑ Preparation of food Hot&cold water for cleaning ®Toilet&hand washing ❑ Store refrigerated food <br /> ❑ StoTe dry food/supplies Provide potable Water Over-night parking Adequate electrical outlets i <br /> d r-- <br /> Signature of Comriiissary Ownerl0 erator Date <br /> HEALTH DEPARTMENT <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 S of 6 MFPU APPLICATION <br /> 7/1812008 <br />