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VERIFICA 0ON OF VEHICLE COmMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): p C d <br /> Address for Vehicle: s C <br /> Street Address City <br /> 1) License Plate #: �1��5 GG 4) Year: ?�0 <br /> 2) Vehicle Vin #: 5) Make/Model: w r) <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: u ckW C) <br /> Address of Owner: rOCAc I <br /> &Ile_qNj <br /> Street Address J i 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 cln ng and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> discontinued, the erm;t holder must notify this office to make the necessary changes. Failure to notify this <br /> office may resinpey' t rev ation and penalties. <br /> 7 30 Z10 ) <br /> Signature of Ve(hi e O rator Dat <br /> COMMISSA INFORMATION <br /> Business N me: , J <br /> Owner Name: ---� <br /> Site Address: r-- <br /> Street Address City <br /> Phone: (2 ) <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 /> nn ; CALIF011� 4!Ifi: CATERING <br /> �( Liquid &solid waste disposal I1� Utensil washing sink Fe i I i <br /> (2 or 3 compartments) Store fra)zESUPPLY <br /> 2440 S. IRPORl-UvAy <br /> ® Preparation of food Hot&cold water for cleaning Toilet&I h� asW§jo 4 to9 ftjerated:'f , <br /> 00 <br /> Store dry food/supplies Provide potable water F/I Overnight parking Adequate electrical outlets <br /> Signature of Commissa Owner/Operator Da e <br /> HEALTH 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 />