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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: �? S S � <br /> Street Address City <br /> 1) License Plate#: % ��j�j 4) Year: <br /> 17-7`7 <br /> 2) Vehicle Vin #: Cp�`3�' Z336 6 l� 5) Make/Model: rv! e I/5/ <br /> 3) State Decal #: 6) Color: u) h / �? <br /> VEHICLE OWNER INFORMATION x" <br /> Name: <br /> Address of Owner: S s - <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 /> 1yZ1e1 <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFOR,MATIO <br /> Business Narne: <br /> Owner Name: SDS' <br /> Site Address: -- <br /> Street-Address City <br /> Phone:o.��) 271'-ZZ�1_4' <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 /> Utensil washing sink '' <br /> L Liquid&solid waste disposal ❑ Store frozen food ❑ Vehicle wash facilities <br /> (2 or 3 eo'mpartments) <br /> 0 Preparation of food 0 Hot&coldwater for cleaning Moilet&hand washing ❑ Store refrigerated food <br /> " <br /> to -dry f od/supplies ®"Provide pot ble water Z'&ernight parking ❑-Fkdequate electrical outlets <br /> _/Z <br /> 'Sign ure of Commissary Owner/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 /> 7/18/2008 <br />