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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> %7T-5. ir �'�'� 1r�.:s'� <br /> = - ii:r <br /> Vehicle Name(DSA): <br /> Address for Vehicle:. <br /> Street Address City- <br /> 1) License Plate#: `�v -914 I 'P 1 4) Year: ` <br /> �` ;� �� 5 Make/Model: <br /> 2) Vehicle Vin# 3 i i i�r�I�� ) , <br /> 3) State Decal-#: 6) Color: N, r <br /> UE LL�' i*ER {�_.._ N a"ta ,r eYR _NRA RM <br /> Name: Iry C --( <br /> Address of Owner: +7 '� _ > C i j ; c c,a c <br /> Street Address I 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&1,14297). 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 /> Signature of Vehicle Operator Date <br /> T �� �iSi7t'1(1< lrl �'s T"} -, _ - � Y.s+._ s.*4-'-F 2'T �_rT '_;c;y F - � J_ �"� -t--./•:''�:v�-.<_..i.. <br /> Business Name: P C i c , C \--1 F0 ,21 <br /> Owner Name: n� c _ - ` 2\;' <br /> Site Address: C — <br /> Street Address City <br /> Phone: <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> ❑ Liquid&solid waste disposal ❑ Utensil washing sink `\©Store frozen food \� Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑Preparation of food ❑Hot&cold water for cleaning❑Toilet&hand washing ❑ Store refrigerated food <br /> ❑Store dry food/supplies ❑Provide potable water Overnight parking Adequate electrical outlets <br /> Signature of Com missa Owner/dperator Date <br /> r n- `w'-� �' -` �� .n---e-.,•-�' o.. ^^� 7•n�'- ->�'�,� 3 MF biz't,. t'-- `: ^� tj a.�' <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 RE HS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />