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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VU,,EHICLE INFQRMATION _ �_,_ __,, x _• _ _ <br /> -_ <br /> Vehicle Name (DBA): OS Wi <br /> Address for Vehicle: 3 b s �L,(i r h G .may <br /> Street Address (� city <br /> 1) License Plate#: l &D 154) Year: l'7/ <br /> q <br /> 21 Vehicle Vin #: ��,�jGP�a �a y 35cnif Make/Model: GMC, 34 0,() <br /> 3) State Decal#: 6) Color: <br /> - - <br /> V,EHICLEf;QWNEREiNFQRMATaONi <br /> Name: J&IjltK Aer :11' 3 <br /> Address of Owner: 2& G <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 /> 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 /> t //dg � <br /> 5 na ure of Vehi le'Operator Date <br /> ICQMMISSARY4INF- TIO <br /> Business Name: l f <br /> Owner Name: <br /> Site Address: (� 7 <br /> Street Address City <br /> Phone: U <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 /> a-Liliuid&solid waste disposaltonsil washing sink <br /> (2 or 3 compartments) <br /> El frozen food ehicle wash facilities <br /> epa a ' of food of&cold ter for cleaning oilet&hand washing ;Adequate <br /> Store rigerated food <br /> for ry food/supplies rovide potable water vemight parking electrical outlets <br /> 117 <br /> Signature of Commis sa Owner/O erator Date <br /> HEALT D RTMENT a <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 /> D 16-017 5 of 6 MFPU APPLICATION <br /> 8/2008 <br />