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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): Zo„ a Clya Address for Vehicle: So j �.0 �+,zLr c+r CtN Sq ko d, CA Street Address City - 1) License Plate#: 5p �} �,� 4) Year: p 2) Vehicle Vin#: �o5) Make/Model: E T Q t_ 3) State Decal#.- _ C f-\ 6) Color: 12 L n VEHICLE OWNER INFORMATION Name: TYY�1�4I�1a �0 7°7�j r� Address of Owner: _ i Q Street Address city The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing (CalCode sections 114293 & 114297). If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office may result in permit revocation and penalties. Si nature 4Vehicle Operator Date COMMISSARY INFORMATION Business Name: Owner Name: 4— rd Site Address: Street Address city Phone: (20 ) Z 2 t-1 34 I, the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: i tensil washing sink Liquid&solid waste disposal Store frozen food Vehicle wash facilities !2 or 3 compartments) �f Preparation of food Not&cold water for cleaningo,Iet&hand washing tore refrigerated food Store dry food/supplies Filfrovide potable water [a6enight parking [r4 Ad_ecluate electrical outlets Signature of Commissary Ownerf0perator Date HEALTH DEPARTMENT If the commissary/food establishment is outside San Joaquin County,the focal health jurisdiction must verify current health permit by signing below. Commissary/food establishment is in County. Signature of County RENS Date EHD 16-017 S of 6 MFPU APPLICATION 7/18!7008