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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />-V-INFOR1VlATl_ON . <br />% <br />Vehicle <br />Vehicle Name (DBA): <br />Address for Vehicle: Tho f l <br />�t �k�r <br />Street Address <br />city <br />1) License Plate #: 1.T+4x-14 <br />4) Year: M -i <br />2) Vehicle Vin #: Vf n6lftb Q 2g3 <br />5) Make/Model: EV <br />3) State Decal #: V <br />6) Color: <br />VEHICLE O.INNER INFORMATION <br />Q I Z, 1 <br />Name: <br />WAV N(WAWLOO <br />Address of Owner: N20 <br />W ' <br />Street Address <br />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 <br />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 />ya ry <br />llo) <br />Si nature of Vehicle Operator-- <br />Date <br />COMMISSARY INFORMATION <br />Business Name: <br />Owner Name:__ <br />Site Address: a rV1 ( A st <br />to" <br />Street. Address <br />city <br />Phone: (2 01 01- 11-41 <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 />,i <br />id & disposal [�blltensil washing sink <br />"e frozen food Vehicle wash facilities <br />LTJ u solid waste <br />(2 or 3 compartments) <br />lotSt <br />Preparation of food &cold water for cleaning Toilet &hand washing ❑ Store refrigerated food <br />/EgProvi <br />❑ fit re ry food/su ies potable water <br />Overnight parking Adequate electrical outlets <br />ature of iss cad erator <br />Date <br />HEALTH DEPARTMENTS <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 <br />Date <br />EHD 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008 <br />