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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): ; 6 Ute; C e,,'w /' 1%4 C I^` C_ S ff d S <br /> Address for Vehicle: / J-, j 7 UCC L)7; r} <br /> Street Address City <br /> 1) License Plate#: f j 9/ K`Y=S 4) Year: / <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal #: 6) Color: GC.U'� /I -� ✓L.�/) <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: 1J 3' Z_ CC Cde ti, _ c'O h > ;JCC K( iti CPr Z6 <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 /> S" nature of V riiarntnr Date <br /> OMMISSARY INFORMATION <br /> Business Name: ti' L 1 a, C. 1 4LkC C-ivy C 2 <br /> Owner Name:. 5& i J`' /' ! F" f`l <br /> G. <br /> Site Address: l 7f 7c L! r, ! %7- <br /> street <br /> street Address City <br /> L— I <br /> Phone: <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 /> �LL d& solid waste disposal t tensil washinc sink <br /> (2 or 3 compartments) Store frozen food Q�Vehicle wash facilities <br /> o'food 0-Hot&cold waver;cr cleaning ©�oilet&hand washinc 0• Store refrigerated food <br /> Q'Provide potable water Q Overnight parking E Adequate electrical outlets <br /> Signature of Commissary Owner/Operator Date <br /> HEALTHIJEPARTMENT <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 />