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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incompleteapplication may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): f\,/&&U YEAJ <br /> Address for Vehicle: 24e4o S 11 I V m Y'+ k6 p etc iJ c A Cj <br /> Street AddressCity <br /> 1) License Plate#: 315`F//��'-7 2 4) Year: <br /> 2) Vehicle Vin#: 4ITC-H F3 2-kXJ33245S,-Make/Model• ,C <br /> 3) State Decal#: 6) Color: 'W 2 <br /> VEHICLE OWNER INFORMATION <br /> Name: (lIJ(DAJ() IjpUyt <br /> Address of Owner: 2--72,(D N 1 A41W l V.)A loC —O/J p <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 resul in permit revocation and penalties. 1 �1211 17 <br /> SiSi natu o Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: ttC-0rti I �� \ <br /> Owner Name: tr) <br /> Site Address: 7,1140 <br /> Street Address City <br /> Phone: ( ) I <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 /> dLiquid&solid waste disposal Utensil washing sinkStore frozen food Ve <br /> (2 or 3 compartments) hicle wash facilities <br /> [/Preparation of food dH0/ot&cold water for cleaning Toilet&hand washing Sig refrigerated food <br /> � Store dry food/supplies drovide potable water Overnight parking Adequate electrical outlets <br /> nature of Commis ary 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 MFPU APPLICATION <br /> 7/18/2008 <br />