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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): —v4o6 <br /> Address for Vehicle: <br /> 1031eet Ad ress • city <br /> 8 nuyb�S c� <br /> 1) License Plate#: f ice/ 4) Year: loo Z <br /> v <br /> 2) Vehicle Vin#: f Make/Model: <br /> 3) State Decal#: _ 106 ) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: ` \4a <br /> Address of Owner: ic)31, rS Qy� <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 permit revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 4 11(�f h th <br /> Owner Name: f� ,,,Site Address: `f _v cam, Air 6! C' � � <br /> Street Address city <br /> Phone: ( G ) / 1 'YES G <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 t?! Utensil washing sink �t'cre frozen food ❑ vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑/Preparation of food Hot&cold water.for cleaning LJ ilet&hand washing ❑ Store refrigerated food <br /> Store dry food/supplies `Provide potable&iter !j Overnight parking ❑ Adequate electrical outlets <br /> �y 1 / 9 <br /> Signature dif Commis ry 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. Cornmissary/food establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 3 MFPU APPLICATION <br /> 7/18/2008 <br />