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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: � �C). r�} �� � � 5 G �-(L�l' <br /> Street Address City <br /> 1) License Plate#: J ( 75' 4) Year: i q.5 L� <br /> 2) Vehicle Vin#: 5) Make/Model: 6' of e- <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: y. G'l�f t,' t <br /> Address of Owner: 0,'C. ,f34) y45—rt,0<T6 5..z 1 P <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 /> ju <br /> SI atur�e of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: Q ` li U f"'� v R 1�C, <br /> Owner Name: ` CC VIA jzc_; <br /> Site Address: S I io t,' S <br /> y C. 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 /> t Liquid&solid waste disposal I=1 Utensil washing sink Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> 'reparation of food Hot&cold water for cleaning aToilet&hand washing Store refrigerated food <br /> Storefood/supplies Provide potable water �vernight parking Adequate electrical outlets <br /> d <br /> � 11':2-1 /(�r <br /> Si nature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissarylfood 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 />