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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#: L 10( 4Year: <br /> 2) Vehicle Vin #: C- r, y�'1 j•tv1^j� h� 5Make/Model: (7M L <br /> 3) State Decal#: 6) Color: fia&tG. <br /> VEHICLE OWNER INFORMATION <br /> Name: N� W�6A <br /> Address of Owner: Jj(LA 1Q-),t6teV,\ c n�`✓ T)f f�1S�Ci ii` <br /> street Address city <br /> The mobile food facility shall operate out o.a commissary and shell report to the commissary at least once each <br /> operating day for cleaning and servicing (CalCode sections 9.14295 & 714297). 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 /> off" a ma result in perms:r Vocation ar d penalties. <br /> �i� iAV <br /> Sigma of VeNcle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 6L If f . Lu SU <br /> Owner Name: c- _,f S J <br /> Site Address: 2 o S. r r — 5�0C g hi4 <br /> street Address City <br /> Phone: (Z-ocj) S > ' <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 L; Utensil washing sink Store frozen food dVehicle wash facilities <br /> (2 or 3 compartments) <br /> separation of food �ot&cold water for cleaning ,�Toilet&hand�a•asliing �Stnre refrigerated rood <br /> U Store dry food/supplies Provide potable water ��Overnight parking .[2/Adequate electrical outlets <br /> Signature o Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT _ <br /> If the commissary/food establishment is outside San Joaquin County, the local health.unsd'iction must verify <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County.REHS Date <br /> s <br /> EHD 18-017 50f6 "FPU APPLICATION <br /> 7f 18/2008 -�'" <br />