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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): C 0'F .d Q G S <br /> Address for Vehicle: 1 —ER 6 7d-N' 9 �3 -c- <br /> Street Address [� City <br /> 1) License Plate* 1 I<E / 7 4) Year: -;-) b �S <br /> 2) Vehicle Vin#: 5) Make/Model: 5 PC /l/ <br /> 3) State Decal #: 6) Color: �i`�fNL�SS S€C L <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: Z 5 c ( -/, S'. (I/c=Gtif C/j 3� <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 & 114297). 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 in pe mit revocation and penalties. <br /> Al !LK-- 7113 45- <br /> Sin re of Ve icle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: (,(/Wp P, <br /> Owner Name: S A L (J 0 k A 4 D <br /> Site Address: S 7D Gk <br /> qStreet Address city <br /> Phone2� vZ ( q -S q),� <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 /> ED<iquid&solid waste disposal Q Utensil washing sink <br /> (2 or 3 compartments) tore frozen food Q Gehicle wash facilities <br /> separation of food EKlot'&cold water for cleaning oilet&hand washing Store refrigerated food <br /> Store food/supplies rovide potable water Q/Overnight parking Adequate electrical outlets <br /> _ 3 <br /> Signature of Commissary Owner/Operator Date <br /> HEALTH 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 /> 7/18/2008 <br />