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VERIFIATION OF VEHICLE COLS%MEIVED <br /> Please provide all information requested. An incomplete application may delay approval <br /> XWO �1C60 � vO . 2� y� <br /> £.: r -�i-✓'�I-�ra i�Afi;dii'avt,".•�Ji ,. _ ...a% <br /> Vehicle Name (DBA): U�r <br /> Address for Vehicle: <br /> street Address city <br /> 1) License Plate#: SLE p't r/i� 4) Year: 114e, ? <br /> 2) Vehicle Vin#: /jT,&jg J ( 1810/5) MakelModel: 6"7—,J) <br /> 3) State Decal M 6) Color: "IVe <br /> saeu r <br /> IIG`LiE�, Rf ext e r s4f��Tlrf <br /> Name: <br /> Address of Owner: X sap <br /> str t Address city <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once <br /> each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the <br /> commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure <br /> to notify this office may result in permit revocation and penalties. <br /> p�Signature of Vehicle Operator Date <br /> NOW <br /> Owner <br /> fix,Sgt""""" <br /> , ?* ..5 ': r Jt' ° " s <br /> ,r r;.? .li%7. , ` _.2Yi4: s' rY!f"5;.' . '. se�'"r't`#'*'. <br /> Business Name: <br /> Owner Name: <br /> Site Address: <br /> street Address city <br /> Phone: (Z m2 <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 /> Liquid&solid waste disposal Utensil washing sink Store frozen foodVehicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food ,Hof&cold water for cleaning Toilet&hand washing ❑Store refrigerated food <br /> 'Store dry food/supplies Provide potable water i9overnight parking Adequate electrical outlets <br /> ���������� Y1�11 <br /> Signature of Commissa Owner/Operator Date <br /> tyA <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 /> EMD 18-013 Page 8 of 9 MFF APPLICATION <br /> 7/31/2009 <br />