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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): Address for Vehicle: ! / Street Address�y City 1) License Plate#: �/ 7 4) Year: 2) Vehicle Vint f G-"93A }f ffl? jly 5) Make/Model: l 3) State Decal#: 6) Color: VEHICLE OWNER INFORMATION Name: d/4/ / Address of Owner: Street Address Ci The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaninq-ald servicing (CalCode sections 114295 & 114297). If the use of the commissary is discontinued the per�tWho er must notify this office to make the necessap changes. Failure to notify this office y ult" e vocation and penalties. I nature of Vehicle rator Date OMMISSARY INFORMATION Business Name: 'P Owner Name: Site Address: f S Street Address City Phone: (k ) I,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: ZLiquid&solid waste disposal ❑ Utensil washing sink ❑Store frozen food L� (2 or 3 compartments) Lyu Vehicle wash facilities ❑Preparation of food Hot&cold water for cleaning Toilet&hand washing r` T 9 ❑ store refrigerated food ❑Store dry food/supplies _Provide potable water K7Overnight parking 9 P 9 Adequate electrical outlets - ' ��1i SI nature of Commissa O� erator Date ��7-- HEALTH 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 REHS RECEIVED err Date EHD 18-017 ENVIMENTAL HEALTH 7/18/2008 P ITISERVICES MFPUAPPLICATION -