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V <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE,INFORMATION. <br /> Vehicle Name (DBA): " f - . <br /> Address for Vehicle: ? .• , �, S <br /> Street Address City <br /> 1) License Plate#: aXUaa%• 4) Year: _ <br /> 2) Vehicle Vin #: IW�/f, ^lP�j��'�5) Make/Model: <br /> 3) State Decal#: l (90 _ _ 6) Color: <br /> VEHICLE OWNER INFORMATION _ <br /> Name: t07U�, 1'1 &Xyr^C Y— <br /> Address of Owner: -7Q?76�-,7 CL Y'1 L-0 Y1(f-- <br /> �� +�✓ <br /> Street Address 4.1.1 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 /> �` Al0 i <br /> Signature}of Vehicle Operator Date <br /> COMMISSARY INFORMATION. " . <br /> Business Name: v U`t,n ' ,s A`t <br /> Owner Name: <br /> Site Address: -- <br /> Street Address City <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 /> 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 d food/supplies ❑ Provide potable water ❑ Overnight parking ❑Adequate electrical outlets <br /> Signature of Commissary Owner/Operator Dat <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside Sari 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 />