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<br /> VERIFICATION OF VEHICLE COMMISSARY
<br /> Please provide all information requested. 'An incomplete application may delay approval.
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<br /> EHICL �NFaRUF 'f7 � .�,;t;: � �
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<br /> Vehicle Name(DBA):
<br /> Address for Vehicle:. S`S,�`' �^ �' �� �:�/?L E' 0,A .
<br /> Street Address city
<br /> 1) License Plate#: `L4)� an:
<br /> 2) Vehicle Vin#: � � ��--`L�j ��� � )v Make//` odel: � c
<br /> 3) State Decay#.: 6) Color:
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<br /> Name'
<br /> Address of Owner: 4
<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 & 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 r(Wxwa#0 and penalties.
<br /> .Signature e`E?er for Date
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<br /> Business Name: j C,K < C R G
<br /> Owner Name: S., i ✓ ti, sl ,Site Address: 0,1 cAj-7-6 -0 1 S-'7— <6^ --b
<br /> Street Address city
<br /> Phone: 0A _1`7 in
<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 F-1 Utensil washing sink(2 or 3 compartments) LJ Store frozen food Vehicle wash facilities
<br /> ❑Preparation of food ❑ Hot&cold water for cleaning`�Toilet&hand washing �� Store refrigerated food
<br /> ❑Store dry foodfsupplies ❑Provide potable water Overnight parking .Adequate electrical outlets
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<br /> Signature of Commissa Owner/O erator Date .' WNL'
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<br /> �1TEAIeTH`DEPAR�MENT-�7�( .� x��,z:� ,;���,, �r ,�� .. ���� •�$ , -• � �` F k�;- , ,
<br /> If the commissarylfood 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 MFPLI APPLICATION
<br /> 7/1812008
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