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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all Information requested. An incomplete application may delay approval. <br /> Vehicle Name(DBA): It k n n CA 0.M <br /> Address for Vehicle: <br /> Street Address-7 City <br /> 1) License Plate#: Z O 2/ O E 4) Year: 10 0 Cl <br /> 2) Vehicle Vin#: Make/Model: C H C\/o R L i=T <br /> 3) State Decal: 6) Color: W <br /> ate+.'lh+++ <br /> NEHjCLEOWN[=R,�NFORMf1�iON .yrs <br /> Name: r- 1 i D A flS1i A F <br /> Address of Owner: o o L i �/µ L f} gC'K I') (\J G <br /> so-eet A drew 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 & 1.14297). 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 suit in permit revocation and penalties. <br /> o 1--2 3 — 2-9) -7 <br /> signature o Vehicle Gperatori OperatorDate <br /> iQAII IS. , F1FCiRAi1 TION y' r eY <br /> Business Name: <br /> Owner Name: SW T , -0 q <br /> Site Address: _3SP 4 G c _ TL <br /> Street Address City <br /> Phone: (0�o) C7 LlT--/ 11 <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 /> ❑ Liquid&solid waste disposal ❑ utensil washing sink ❑Store frozen food ��Vehicle wash facilities <br /> (2 or 6 compadments) <br /> ❑Preparation of food Hot&cold water for cleaning'-E Toilet&hand washing Store refrigerated food <br /> ❑Store dry food/supplies ❑Provide potable water Overnight parking electrical outlets <br /> Si nature of Commrssa Owner/ erator Date <br /> HEA" FI{DEPICTI(fE y g �r <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 RE HS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/16/2006 <br />