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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEM061F NtFORMATION= Vehicle Name(DBA): Address for Vehicle: U Q Street Address city 11 x� 1) License Plate#: 1 P �✓� 4) Year: -0 ! l 2) Vehicle Vin#: 5) Make/Model: Si'(SINS 3) State Decal 6) Color: I EHI_CLEOWNEi2INFORMATION E Name: MOO Mrbs' II Address of Owner: S Street Address City I The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is discontinued, the permit ust notify this office to make the necessary changes. Failure to notify this office ma resulilt ermit revocation nd penalties. _ X�O �o 9 Sin ure of Date Cy0 ISSARY,INFORMATION Business Name: I IIffilm cylFUT10 Tru S Owner Name: Site Address: 0 (Efornim R, ' -_Street Address city Phone: ( ) 2-11 - 1141 I,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: {/,/, A/ U Li -id&solid waste disposal Lv� utensil washing sink ❑ Store frozen(nod VehiGe wash facilities (T'or 3 compartrnents) Preparation of food Q!!H t&cold water for cleaning To' t&hand washing ❑ Stora refrigerated food QSto dry foods /�vide potable water might parking Adequate electrical outlets tolli) 1";7 S ture of m' sa rator Date HEALTHrDERA. _- NT-; - ,: If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify current health permit by signing below. Commissary/food establishment is in County. Signature of County REHS Date EHD 16-017 5 of 6 MFPU APPLICATION 7/18/2008