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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: 0 4) Year: '�� <br /> 2) Vehicle Vin#: Vt � �l ( V� �?�, 5) Make/Model: <br /> 3) State Decal#: / � �� � �� 6) Color: �� <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: ��7 Taro 01�how T� L <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 & 11429711, 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 inpermit revocation and penalties. <br /> Signature of Vehicle Operato Date T <br /> 'C0MMISSARY INFORMATION f <br /> Business Name: 0 1 U 1iiI Hn <br /> Owner Name: ' �.��/' � s! ffjj <br /> Site Address: <br /> Street Address city <br /> Phone: ( / ) 11 <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> compissary as checked below: / <br /> i <br /> 0 <br /> "quid&solid waste disposal Utensil washing sink ❑ store frozen food ET Vehicle wash facilities <br /> (;/or 3 compartments) <br /> P eparation of food ❑✓�Fjot&cold water for cleaning RfToilet&hand washing ❑ Store refrigerated food <br /> V <br /> re dry food/ u plies r_�P,rovide potable water ffovemight parking Adequate electrical outlets <br /> r iI <br /> � Date`� 1� I �� <br /> ture of CdrnPrnss 4wnerf0 gyrator <br /> H�fcALTH 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 /> 711812008 <br />