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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate#: 17W73 4) Year: <br /> 2) Vehicle Vin#: r TR C i'f 4,114q'�5(; 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER.INFORMATION <br /> Name: Th t;w�ct J ��i✓� <br /> Address of Owner: Or <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�j in p chit revocation and penalties. <br /> Si nature of Vehicle Operator Date <br /> C0MMISSARY INFORMAyThION <br /> .Business Name: <br /> Owner Name: S� n� (- <br /> Site Address: SSP cr Cg 'C- N D S—o c-J, 7-c jv c C-7 57 <br /> Street Address city <br /> Phone: (_�;bq o� k�r- /-�Ll c-( <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 Store frozen food ❑ Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washing �❑ Store refrigerated food <br /> ❑ Store dry food/supplies ❑ Provide potable water \❑ Overnight parking \❑Adequate electrical outlets <br /> PICK IN GO ICE CT-,\ni_r <br /> 3588 E. CARPENTL D. <br /> Signature of Commiss Owner/Operator Date <br /> HEALTH„ <br /> 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 /> 7/18/2008 <br />