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MFPU APPLICATION <br />VER11FIICATkM OF VEHOCLIE COMMISSARY <br />Reese provide all inforrnagon requested. An incomplete application may delay approval. <br />VEHECLE..11NFORWOCim <br />I Vehicle Name (DEN: <br />Address for Vehicle: <br />Street A&lem <br />VEHICLE CaftfAERIEVORilliM10 ' <br />Name: <br />Address of Owner: 363 ( <br />License Plate #: 5i75 4) Year: <br />Vehicle Vin 33g 72r ?X <br />State Decai <br />N27905) Make/Model: <br />6) Color: <br />Street Add <br />City i The mobile food facility shaii Operate out of a commissary and shall report 'c the commissary. at least once each i operating day for cleaning and servicing (C-alCode seotions 114205 es 114207). if the use of the commisSery is office rt pe <br />f discontinued, the per holder illUat norify this of m fice to maize the necessary changes. Failure to notify this m- esul in rmit rev 4.t nd penalEies. -) <br />E .111111...... . : <br />' R :-: <br />1 <br />Date <br />Business Name: r <br />i Site Address: <br />Owner Name: 1/4,3-1 R <br />St-eel:Address <br />Phone: (2coo (01A- irt 15 le) <br />commissary as checked below: the cornmissenj owner, can and will provide the necessanj facilities for the above mentioned vehicle at my <br />Signature of Vehicle 0 erator <br />I'M I 8 BA ilitFoRilfii,MORI.: <br />pr I <br />Cily <br />Liquid & solid waste disposal Ni (U212a:scilothiT sink <br />Preparation of food Hot & cold water for cleaning <br />StyrCidry food/supplies Provide potable water - / <br />Signature of Commt <br />Toilet & hand washing <br />Overnight parking <br />3 19 <br />Store frozen food E: Vehicle wash facilities " <br />El Store refrigerated food <br />Adequate electrical Outlets <br />RAF:TREAT <br />!f the corarnissafy/food establishment is outside San joaquin County, the local health jurisdiction must verify ::urrent health permit by signing beim!. C;ornmisseryifood establishment is in :;oungr. <br />3ignature of Courtly REHS <br />)16-01T ;1200B 5 of 6