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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): ' Q <br /> Address for Vehicle: a 9d� �, y eo <br /> Street Address City <br /> 1) License Plate#: 4) Year. /y�tf <br /> 2) VehicleVint. IG!}>'Q3 /(j(J35'03D9S5) Make/Model: GM(!�' <br /> 3) State Decal#: ( 6) Color: -Zztf' L <br /> VEHICLE OWNER INFORMATION <br /> Name: nC <br /> Address of Owner-X 73VC, aQ. <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 /> discon ' ued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office Aay result in rmit revocation and penalties. <br /> c '/q S - I. - I �5 <br /> .Sig ature of Vehicle Operator Date <br /> C MMISSARY INFORMA ION <br /> Business.Name: 4A <br /> Owner Name: . t ` <br /> Site Address: JQ ; Qs <br /> Street Address zity <br /> Phone: 00? ) <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 /> hi <br /> wasn <br /> ® L quid&solid waste disposal Utensilg sink ❑Store frozen food Vehicle wash Facilities <br /> (2 ora compartments) <br /> ❑ Preparation of food Hot&cold water for cleaning ®Toilet&hand washing ❑ Store refrigerated food <br /> ❑ Store dry food/supplies Provide pole water Overnight parking EfAdequate electrical outlets <br /> Signature of Commis Owner/Operator ! Date <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 WPU APPLIOA nON <br /> 7/18/2008 <br />