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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): 4 lei G l S f7 Q 066 5 <br /> Address for Vehicle: 3,153 D �f x C�EE�� 5 7�)( �R-To � C fi J� 1 <br /> Street 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: 6` A)T0/W/ L <br /> Address of Owner:5'63C) F-Ok' STbckTb(U C Z d <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 /> operatingy 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 /> office may kiiisu#in permit revocation and penalties. <br /> Si ure of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> alVl( ti C TeR Uck c �nl � <br /> Owner Name: '72660, C <br /> Site Address: % 7 S, L/ U/D20 s T S-FOC- b <br /> Street Address City <br /> Phone: ( O IR - <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 /> Q Liquid&solid waste disposal Utensil washing sink tore frozen food [t/vehicle wash facilities <br /> (2 0 3 compartments) <br /> separation of food Hot&cold water for cleaning 0/Toilet&hand washing St re refrigerated food <br /> I S/tore d food/supplies lies Provide potable water dOvemig t pa ing Adequate electrical outlets <br /> �' dry PP � <br /> Signature of Commissary Owner/Operator Date <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 />