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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): ) JY N Address for Vehicle: <. r\A C,i Street Address City 1) License Plate#: 4) Year: 2) Vehicle Vin #: 5) Make/Model: 3) State Decal #: 6) Color: VEHICLE OWNER INFORMATION Name: cr c.-, h, Address of Owner: e,f ea . 6, Street Addresb City The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this offices in permit revocation and penalties. ►� Si na re of Vehicle Operator Date COMMISSARY INFORMATION Business Name: Owner Name: Site Address: !,n er l o cn ► rl • '• Street Address City Phone: (,Z11 I,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: ❑ Liquid&solid waste disposal ❑ Utensil washing sink (2 or 3 compartments) ❑ Store frozen food ❑ Vehicle wash facilities ❑ Preparation of food ❑ Hot&cold water for cleaning ❑Toilet& hand washing ❑ Store refrigerated food ❑ Storecdry food/supplies ❑ Provide potable water ❑ Overnight parking ❑Adequate electrical outlets sK'N GO ICE TRE RD ARPEN..ER . Signature of Commisr5ky Owner/Operator Date " "nJ ;'^ SCA 95215 HEALTH DEPARTMENT If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify current health permit by signing below. Commissary/food establishment is in County. Signature of County REHS Date EHD 16-017 5 of 6 MFPU APPLICATION 7/18/2008