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.. . <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): <br />(e>CI <br />t,LA,t <br />Address for Vehicle: <br />Street Address <br />City <br />1) License Plate #: <br />4) Year: <br />J) <br />2) Vehicle Vin #: t t (06tt ' !Aj yJ214 06 edie>(p <br />5) Make/Model: <br />3) State Decal #:� � <br />6) Color: <br />VEHICLE OWNER INFORMATION <br />Name:},,F t �,t./t i -ii Cc(_ <br />Address of Owner: `�6 LICrte. �' <br />Street Address <br />City <br />The mobile food facility shall operate out of a commissary <br />and shall report to the commissary at least once each <br />operating day for cleaning and servicing (CalCode sections 114295 & 114297). <br />If the use of the commissary is <br />discontinued, the permit holder must notify this office to <br />make the necessary <br />changes. Failure to notify this <br />offi y� may result i errp it revocation and penalties. <br />Signature of Ve icle Operator <br />Date <br />COMMISSAR`/ INFORMATION <br />Business Name: <br />Owner Name: <br />Site Address: <br />Street Address <br />City <br />Phone: <br />I, the commissary owner, can and will provide the necessary <br />facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />I/Liquid & solid waste disposal r Utensil washing sink <br />Store frozen food <br />Vehicle wash facilities <br />(2 or 3 compartments) <br />Preparation of food Hot & cold water for cleaning <br />Toilet & hand washing <br />i <br />Store refrigerated food <br />,1/'\d <br />,, <br />AStore,�iry food/supplies, _ ?� Provide potable water <br />Overnight parking <br />, Adequate electrical outlets <br />/ <br />s <br />I 1II C kct <br />j) <br />Signature of ComMissary Owner/Operator <br />Date <br />HEALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local health <br />jurisdiction must verify <br />current health permit by signing below. Commissary/food <br />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 />