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� �6tenD— l„ MQ )(2.1f7t) C, VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION . „ Vehicle Name (DBA): TaCO S a GY}7Ji7t° Address for Vehicle: StreetAddress City 1) License Plate#: 2, re' ! 06L �- 4) Year: 2) Vehicle Vin#: 16 YZ-?2MS-V?3 13L1 5) Make/Model: 3) State Decal#: 6) Color: VEHICLE OWNER INFORMATION,.,, Name: 19n _ A C 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. S�nature of Vehicle O erator Date CO MMI$SARYINFORMATION Business Name: aY� Owner Name: j Site Address: Street Addressity Phone: Qpj) 1,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 Zutensil washing sink (2 or 3 compartments) Store frozen food Vehicle wash facilities Preparation of foodot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food Store dry ood/supplies Provide potable water -E�Vernight parking Adequate electrical outlets 6 /f his Si t re of Commissary Owner/Operator Date PEACTH DEPARTMENT" 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 " Date EHD 16-017 5 of 6 MFPU APPLICATION 7/1 BM08