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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): Address for Vehicle: Street Address city 1) License Plate#: _:A: 7=�-6� % 4) Year: ] z 2) Vehicle Vin #: UTaF1y 9.53i�. j Make/Model: A MC 3) State Decal #: _�: 6) Color: t e- VEHICLE OWNER INFORMATION Name: Address of Owner: Street Address City 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 holder must notify this office to make the necessary changes. Failure to notify this office may result in permit revocation and penalties. Signature of Vehicle Operator Date w COMMISSARY INFORMATIONy ._r :3 k Business Name: C p C C E Cr1 Owner Name: A fy 6 11-( Site Address: 3 Sir 'F. C S'Tn G K 70 Street Address city Phone: (%on �A _ --) I,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: ❑ Liquid&solid waste disposal ❑ Utensil washing sink (2 or 3 compartments) ❑ Store frozen food IQ Vehicle wash facilities ❑ Preparation of food ❑ Hot&cold water for cleaning Toilet&hand washing `�Store refrigerated food ❑ Store dry food/supplies ❑ Provide potable water Overnight parkingAdequate electrical outlets PICI GO?CE CREAM )� - -�j o\T7.. CARPENTER RD. Signature of Com missal Owner/Operator Date , t 'TON,CA 95215 HEALTH DEPARTMENT k 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 RE HS Date EHD 16-017 5 of 6 MFPU APPLICATION 7/18/2008