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VERIFICATION OF 'VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> V�Ef=ii'C1IFORMiOtil <br /> Vehicle Name{DBA): =L �.0�'t )rDLk M > ! L <br /> Address for Vehicle: S", I 110i<" '!5P1 • _ , k.1_ <br /> Street Address city <br /> 1) License Plate#: J� 4) Year. ' j <br /> 2) Vehicle Vin#: ( Ni.S�= :; Jr2 t.5) Make/Model: <br /> 3) State Decal#: 6) Color: IGt t. <br /> t <br /> EEfCEaONNER=TNORAAATtQN <br /> Name: J(NA YV1`1f CA Jen241U Lot) +11 <br /> Address of owner: �.EU - �1/l�w11�'/1� 1 0 S 3` <br /> j i� - l��. At G J 1/`� I <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 /> ll office may,result in permit;-revocation a0d penalties. / ) <br /> /h <br /> Si6nature of Vehicle Operator . Date <br /> .GQ1VIiV11SSAFi1'`�NFORMATiON- - - <br /> Business Name: t A <br /> Owner Name: - <br /> Site Address: , <br /> Street Address city <br /> Phone: (20d .1' `1) a�71 ell <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 /> ❑Liquid&solid waste disposal EZ-0tensil washing sink ❑ Store frozen food ❑'V2hide wash acilities <br /> (2 or,3-compartments) <br /> ®'Preparation of food E t Hot&cold water for cleaningoilet.&hand washing ❑ Store refrigerated food <br /> ✓r dry food/stlpplies E'er rovide potable water M'Ovemight parking Adequate electrical outlets <br /> 4�1;,t 1 <br /> Si nature of Connmissa Owner/Operator Date �-Cf <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 i <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 711812008 <br />