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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): ' <br /> Address for Vehicle: ,yam, J <br /> Street Address V City <br /> 1 Ull a U2� CCI�-A- <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal #: 6) Color: �(t r <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: 6y 7S3O <br /> Street Address ICity 11 <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 (CalCode sections 114295 & 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 result in permit revocation and penalties. <br /> Si re of'vehiQ6,6perator Date <br /> C MMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: <br /> Street Address City <br /> Phone: <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 ❑ Store frozen food 2rVehicle wash facilities <br /> (2 or 3 compartments) i <br /> ❑ Preparation of food lot&cold water for cleaning ❑ Toilet&hand washing ❑ Store refrigerated food <br /> ❑ or, dry food/supplies ❑ Provid able water PAvernight parking El Adequate electrical outlets <br /> s,� / p <br /> Si nature of ComrAssary Owner or 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 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />