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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): /- kG k- I` 2 <br /> Address for Vehicle: ?Z) - & 6776, <br /> Street Address City <br /> 1) License Plate#: •�,>( /lf 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: q ) j <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). 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 /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: f t� L R <br /> Owner Name: <br /> Site Address: 1 7 5 <br /> Street Address City <br /> Phone: ( ) '9' -5 <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 /> W'Liquid&solid waste disposal Utensil washing sink ©Store frozen food [Z]/Vehicle wash facilities <br /> (2 or 3 compartments) <br /> 19/preparation of foodH t&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> EfStore dry food/supplies Provide potable water 0 Overnight parking ©"Adequate electrical outlets <br /> �t <br /> Si nature of Commissa wner/Operator 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 />