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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE. INF'ORMIATION <br />Vehicle Name (DBA): <br />Addi,ess for Vehicle: <br />Street Address city <br />1) License Plate #: 1N 4) Year: 2-0 <br />2) Vehicle Vin #: ��(/S �(1 Z�j(��5) Make/Model: <br />3) State Decal #: CA 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: <br />Address of Owner: W04 S v n f 6' � 0 <br />J` <br />Street Address J 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 & 11429;)_ 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 m5V, result in permit revocation and penalties. <br />--y, 0 --, r Ti <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: <br />C^� f S <br />ra <br />Owner Name: SV I <br />y� <br />�n a U r lli m m n <br />Site Address: - <br />Street Address city <br />Phone: ( Zoq ) ZJ i - 11-2 y <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 />LiquidUtensil washing sink <br />&solid waste disposal ❑ Store frozen food ❑ Vehicle wash facilities <br />(2 qt3 compartments) � <br />M'�Preparation of food Hot'& cold water for cleaning ❑,Toilet &hand washing ❑ Store refrigerated food <br />L�Stote dr food/su i s Provide potable water 'Overnight parking ❑Adequate electrical outlets <br />f <br />Si ' ature of Co'MmAss' . Owner/Operatdr Date' <br />- <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 />