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RECEIVED <br /> VERWPC AT`ON OF VEHICLE COMMISSARY JAN 2 5 2010 <br /> Please provide all information requested. An incomplete application may delay approval.ENVIRONMENTAL HEALTH <br /> VEHICLE W ORMATION RVICES <br /> Vehicle Name(DBA): <br /> Address for Vehicle: ; .�'� �l /� , • ; G�. S �� i <br /> ( Street Address City <br /> E � <br /> 1 1} License Plate#: �� 4/!: 4) Year: <br /> 2) Vehicle Vin# (. 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OUlfNEP,0MFORMATION <br /> Name: <br /> AddresiVof Owner. , �� - , c� <br /> Street Address city <br /> 4 the mobile food facility shall operate out of a commissary and shalt report to Etre commissary at least once each <br /> operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> s discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office <br /> may result in permit revocation and penalties. <br /> Signature of Vehicle Operator Date 3 <br /> Oli{dMISSARY 9NFORU TIQi <br /> Business Name: <br /> Owner Name: C'�- R. C.�r\•, ` ���`r�G��tT�C •Site Address: N00 E K( q(5) <br /> ss h I <br /> Street Addre �— City <br /> e Phone: <br /> I <br /> i, -he commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissarlr as checked below: <br /> x <br /> Liquid&solid waste disposal IA76 Utensil washing sink Store frozen food )' Vehicle wash facilities i <br /> i (2 or 3 compartments) <br /> ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washingIQ Store refrigerated food ti <br /> i <br /> s ❑St dry food/supplies j Q Provide potable water j Overnight parking Adequate electrical outlets <br /> i Signature of Cornmrssary OwnerlO era4,,1 Date <br /> JE-ALT H i-�EPARTMEW <br /> i <br /> r I;the conamissarylfood establishment is outside San Joaquin County,the local health jurisdiction muss:verify <br /> f current health permit by signing below. Commissarylfood establishment is in <br /> Countif. <br /> c <br /> Signature of County REHS Date <br /> END 16-017 5 of 6 MFPU APPLICATION <br /> 711812008 <br />