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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): h1CCL�('01'\l/-t C ff S <br /> Address for Vehicle: j 2_ f_'<_C_ ;Imo' t% �- !l 7l STSG Crt� ` 5�e~'- <br /> Street Address City <br /> 1) License Plate t `f/fin H {}(S- 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: t�(2L/) <br /> 3) State Decal #: 6) Color: G.L.!/-/ (-I— kc-1) <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: <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 /> 113 <br /> S' nature of V 'brator Date <br /> COMMISSARY INFORMATION <br /> Business Name: U C, t, L J - 1/�L, ck " lv�i`C <br /> Owner Name: J /�` : /-, / 'p () <br /> Site Address: -? , <br /> F r; <br /> Street Address City <br /> Phone: ( ) 5' ._ <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 /> FJ <br /> oj:d &solid waste disposal Utensil washing sink Store frozen food FIVehicle wash facilities <br /> (2 or 3 compartments) <br /> o'`ood a riot&cold water for cleaning ©toilet&hand washing L Store refrigerated food <br /> _ - __ _ _•ores rovide potable water 2Overnight parking Adequate electrical outlets <br /> ell <br /> SicnaLre - ssaa Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissaryMood establishment is outside San Joaquin County, the local health jurisdiction must verify <br /> current health permit by signing below. Commissarylfood establishment is in <br /> County. <br /> Signature of County RENS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />