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VERIFICM ION OF VEHICLE COMmISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION . <br />Vehicle Name (DBA): w-1 S O <br />L <br />Address for Vehicle: <br />Street Address <br />ACity <br />1) License Plate#: Z�. �Q0'72.. 4) Year: <br />2) Vehicle Vin #: 5) Make/Model: <br />3) State Decal #: u2Ttr��] �j QZo 6) Color: W(Ai bL <br />VEHICLEOWNER' INFORMATION <br />_ <br />1 , n �pp� <br />Name: I l l C C r l I U V� t C, A r 'l 4.S <br />Address of Owner: on KA'P'�em- <br />onfO t i�1 j <br />Street Address iCity <br />The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br />operatin day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br />disco i u ,d, the permit hol er must notify this office to make the necessary changes. Failure to notify this <br />off m y exult i 3e vocation and penalties. <br />I 0 <br />Si nat re of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: <br />Owner Name: j1W <br />Site Address: .sO(v�nu� <br />; Jxe <br />,` SiI Adc!4 r.T?j City <br />Phone: �l 0L Z,-" <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 />2/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 & hand washing ❑ Store refrigerated food <br />/Tgilet <br />❑-&ore-dry_fOpd/s1u pl es❑Provide potable water LJ vVernight pa king" Adequate electrical outlets <br />�� <br />� IC� <br />SI natlre f ommissar Ow-n —31-1&perattor Date <br />HEALTA'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 />7/18/2006 <br />