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VEHICLEINFORMATIO <br />Vehicle Name (DBA): <br />Address for Vehicle: ( t <br />Street Address LJ\ <br />City <br />14.-Liquid & solid waste disposal <br />Li Preparation of food <br />Utensil washing sink <br />(2 01 3 compartments) <br />aHOt & cold water for cleaning <br />1.111 Store dry food/supplies <br />."," • <br />/ it/u1 <br />Provide potable water <br />rator Si_Qnkire of Commissary Own r/ <br />HEALTH .DEPARTMENT /7 <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />License Plate #: rf.7- 4) Year: <br />Vehicle Vin #: 2((5) Make/Model: <br />State Decal #: 6) Color: <br />VEHICLE OWNER INFORMATION . <br />Name: <br />Address of Owner: <br />Street Address ) I <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 rpa esult in permit revocation and penalties. <br />-§i-grlature of vAidepirr <br />COMMISSARY INFORMATION <br />ars, <br />/7 s 71- &LITT/ i.-)14 <br />L <br />Street Address <br />City 3(-1. ri (4 <br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: <br />, j/J'' <br />Date <br />Business Name: / <br />Owner Name: <br />Site Address: <br />Phone: 0-0 <br />Store frozen food Vehicle wash facilities <br />Nrioilet & hand washing El Store refrigerated food <br />T(o-vernight parking I:(Adequate electrical outlets <br />Date <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 County. <br />Signature of County RE HS Date <br />EFID 16-01Y <br />7/18/2008 5 of 6 MFPU APPLICATION