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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> P <br /> VE�i1CLEI77 <br /> PR <br /> ,�O, MAT�O�I,'wk� y 'MAW <br /> Vehicle Name (DBA): <br /> N!avi'4 J0 <br /> la VA <br /> Address for Vehicle:3-�l;0 GYe-("vV00d c-L <br /> Cr,� <br /> Street Address City <br /> 1) License Plate#: LEO-11911 4) Year: <br /> 2) Vehicle Vin #: ( L 7 R IjP � . YXV I TT i4'3 Make/Model: <br /> 3) State Decal #: L(--A 6) Color: <br /> VEHICLE,.. .WNERrNFO�RMATION <br /> Name: L. .. T �f�_✓ <br /> I <br /> Address of Owner: 'U P0 <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 /> Si nature of Vehicle Operator Date <br /> Business Name: " <br /> Owner Name: <br /> Site Address: - <br /> Street A dress <br /> Phone: ( e Z j) — S- <br /> City <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 ❑ Utensil washing sink <br /> (2 or 3 compartments) Store frozen food❑ � Vehicle wash facilities <br /> ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> ❑Store dry food/supplies Provide potable water N17-7 <br /> parking Overni ht <br /> 9 P g (�Adequate electrical outlets <br /> SI nature of om missar O erator ��2 �- <br /> HEALTH DEPARTMENT,,` Date7.1 <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 RE HS Date <br /> EHD 16-017 <br /> 7/18/2008 5 of 6 MFPU APPLICATION <br />