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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: % n <br /> S reet Address City <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin #: 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: N .� C 6 <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 /> ,, 02 - 1z- 1-7 <br /> SI nature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: I C k tj iV-er c&m <br /> Owner Name: ` <br /> Site Address: • kon , 952 IS <br /> Street Address City <br /> Phone: <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 /> ❑ 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 /> _XCK'N GO TCE CREAM <br /> 1 R 58 E,,. C7AR,PEE NTER RD. <br /> Signature of Com Issa Owner/Operator Date CA 95215 <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 />