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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE�IN OF RMAATION'�� w4R715A , <br /> Vehicle Name (DBA): �i <br /> Address for Vehicle: 2- V-" i — ZC: C-A6TTNCA <br /> Street Address City <br /> 1) License Plate#: rm v 4—a l4 Year- <br /> 2) Vehicle Vin#: 2 (;O �F O� 5Make/Model: �- <br /> 3) State Decal #: r'� 6) Color: S \ \ V e/✓ <br /> '- t.i`w4pMyN' 6 PuhUYLfdC 1 A7P 'F;frP: WC ... .. 'j'. •�y, <br /> VEHLCLEOWNERI ,FORMATI.ON <br /> Name: —Q <br /> Address of Owner: L1 S tiJ C� <br /> Street Address itY <br /> The mobile f d facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operating d for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinu , the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> off a ay suit in permit revocation and penalties. <br /> Si n to e of Vehicle Operator Date <br /> COM._.ISSA�INFORMATION <br /> Business Name: <br /> Owner Name: d <br /> Site Address: a -j3 Q 'SLMy-\ <br /> Street Address City <br /> Phone: go ) '2_>2�J <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 ' <br /> 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 /> ❑ Stor ood/s Provide potable water ❑ Overnight parking ❑Adequate electrical outlets <br /> 1�_ 1 � - k� <br /> SI miss w er/O erator Date <br /> HEAL <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 />