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MCEIVE® <br /> VERIFICATION OF VEHICLE COMMISSARYE fAPR 2 7 2017 <br /> Please provide all information requested. An incomplete application may delay app ro l;ONWNTAL)IF <br /> [ <br /> VsEglviS <br /> �V,EHIELE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: L4 C <br /> Street Ad res. city <br /> 1) License Plate#: >i PU t,c , a 4) Year: 1.),p1'7 <br /> 2) Vehicle Vin #: t ( -p S%,ctFzi 5) Make/Model: " Z'-:xVA <br /> 3) State Decal* 6) Color: l,1Ei i� <br /> "uVEHICL'E OWNER INFORMATION,._ f <br /> Name: <br /> Address of Owner: i,ck e, cicka <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 ermit revocation and penalties. <br /> n ehicle Operator .-Dafe <br /> lCOMMI SA -INFQRMA-ION r 1 <br /> Busines ame: a <br /> Owner Name: <br /> Site Address:?m5- Pick IgytOp <br /> Street Address city <br /> Phone: (70`1 ) 135Z - (OO O <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 U Utensil washing sink <br /> (2 or J compartments) Store frozen food Vehicle wash facilities <br /> ❑ Preparation of food EI Hot&cold water for cleaning L'J Toilet&hand washing ff Store refrigerated food <br /> L� Sto e dry food/supplies �Provide potable water ❑ Ovvernight parking ❑Adequate electrical outlets <br /> 1 <br /> na re of mmissa Owner/0erator 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 />