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VERIFICATION OF VEHICLE COMMISSARY
<br />Please provide all information requested. An incomplete application may delay approval.
<br />.,.
<br />Vehicle Name (DBA). I w_oS Los
<br />Address for Vehicle: /37)/ ( cc- ts-f-if,e7A 171- -1/ ch (II, c)- /()
<br />Street Address City
<br />License Plate #: 1-1 57 60-1 4) Year:
<br />Vehicle Vin #: 1 6. 5 ice 3 2 (•) rsA53o- z4e5) Make/Model: GPic V A
<br />State Decal #: 6) Color: k.„) tA'e-i-e
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<br />Name:
<br />Address of Owner:
<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 (CalCode sections 114295 & 114297)7 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 />-4s? / "(2-I , 2,
<br />i 0 nature of Vehicle 0.erator Date
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<br />Business Name: 6S- k .
<br />Owner Name: --pl..) i"
<br />Site Address: . r,
<br />i e _ A, ./ if 5./i,,i
<br />Street Address City
<br />Phone: (2) 7-3 t/," c 23
<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 />— —
<br />y Liquid & solid waste disposal 1 Utensil washing sink i Store frozen food 2 Vehicle wash facilities (2 or 3 compartments)
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<br /> Preparation of food Hot & cold water for cleaning [..- Toilet & hand washing 7 Store refrigerated food
<br />Store dry food/supplies Provide potable water gi Overnight parking E Adequate electrical outlets
<br />7 ,
<br />4 .'' - 9 5--/Z ,,7--
<br />S l inature of C m missa Own erator )ate
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<br />If the commissary/food establishm it is cutside San Joe quit-, cunty, the loc., "tealth jurisdiction must verify
<br />current health permit by signing be lw. Commissary/focd et )1ithment is in
<br />County.
<br />Signature. of County RENS De
<br />EHD 16-017
<br />5 of 6
<br />MFPU APPLICATION
<br />7/18/2008
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