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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION p <br /> Vehicle Name (DBA): '' �wrJ �vvclC <br /> Address for Vehicle: Ug - v. <br /> Street Address City <br /> 1) License Plate #: V x-7 22 4) Year: 7_c7�i l <br /> 2) Vehicle Vin #: t ��1 C 7 �2I iIf Iq ) Make/Model:/ rUa, (eJ <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: a e t <br /> stree 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 pe it revo and penalties. <br /> Z <br /> �C�73r1 <br /> Si nat Vehicle operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: . - <br /> Owner Name: J <br /> Site Address: <br /> tree[Address City <br /> Phone: (Z(3C 2 r <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> Li uid &solid waste disposal Utensil washing sink Store frozen food <br /> q (2 or 3 compartments) [J vehicle wash facilities <br /> LPreparation of food of&cold water for cleaning oilet&hand washing al-5tore refrigerated food <br /> 12 Store dry Food/supplies rovide potable water vernight parking Adequate electrical outlets <br /> � 1 e-ZT- Zt <br /> Signature of C missary 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. Commissary/food establishment is in <br /> County. <br /> Signature of County REHS <br /> Date <br /> EHD 16-0 i 7 <br /> 7.182008 5 of 6 MFPU APPLICATION <br /> a-,__. <br />