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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 <br /> NFORMATION Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: ,i5r` q 05 '&P 4) Year: I C1 q <br /> 2) Vehicle Vin#:CP43_ ��, Q _Z 8�- 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER:.,INFORMATION <br /> Name: _ <br /> Address of Owner: UCSI ow <br /> street Address ` <br /> 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 O erato Date <br /> CQMMISSARY INFORMATION- <br /> Business Name: <br /> Owner Name: <br /> Site Address: !- <br /> Street Address City <br /> Phone: �b ) g3 c/ <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 /> k i <br /> washing sink Liquid&solid waste disposal Utensil wastore frozen foodicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food IkKot&cold water for cleaning oilet&hand washing V;-8ti0_re refrigerated food <br /> (['Store dry food/supplies VXrovide potable water [ZWernight parking ©equate electrical outlets <br /> oma. rte,rla -2 23. <br /> Si nature of CO.Ti �issaOwner/Operator Date <br /> HEALTH> PARTWNT <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 RENS Date <br /> 7/1812000808 S of 6 MFPU APPLICATION <br /> 7!18 <br />