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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> r�u qtr t3 [.nm, xwn rua Y s i i r, ) 'N" S tx�I i >fi, i' I tk':,J` ,/ ,'���•Ril f tY$„I2 <br /> tVEHICLErINFORI ATION <br /> \ a <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Address city rte, <br /> 1) License Plate#: n i D 25 ��• 4) Year: <br /> 2) Vehicle Vin#: 1 C�P�L'�� (�lbl�5) Make/Model: <br /> 3) State Decal #: t 6) Color: <br /> ;bUEHICL•,EsEMNRMATION <br /> Name . . ®WNFOa <br /> Address of Owner: al(� " r_ �lU1 CA <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 i ermit revocation and penalties. f y <br /> Signatuu�ofVehlcl�j <br /> /Uf U.f <br /> —� Operator Date <br /> ,COMMISSARYf INFORMATION, <br /> Business Name: cy <br /> Owner Name: V&W ro <br /> Site Address: zo s �u >Z Q k? <br /> Stree Address city <br /> Phone: ('2d11) <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 3 compartments) <br /> Preparation of food P�J,,H�ot&cold water for cleaning Toilet&hand washing Store efrigerated food <br /> f/ Store dry food/supplies t/Provide potable water Overnight parking Adequate electrical outlets <br /> Signature of Commissa Owner/Operator Date <br /> ZT?�' <br /> HEa�THPDERaizTMENT'f" ) <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 />