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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): �.� ''-� I �(/i Iii r'c l �( c< ( <br />Address for Vehicle: 7 DU `;, L- I � (- <br />Street Address <br />City <br />1) License Plate #: �5 1 4) Year: <br />2) Vehicle Vin #: t is GL :511Y214DA0O " 5) Make/Model: <br />R)> '59 <br />3) State Decal #: 1 'i o ( 6) Color. <br />VEHICLE OWNER INFORMATION <br />Name:) <br />Address of Owner:7j <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). <br />If the use of the commissary is <br />discontinued, the permit holder must notify this office to make the necessary <br />changes. Failure to notify this <br />office may result in err it revocation and penalties. <br />, <br />Signature of Ve icle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: I l I :I ' .("I r',, <br />Owner <br />Owner Name: t ,(_� - . ( 6 . (I �� <br />Site Address: `7 `- _ c <br />Street Address <br />City <br />Phone: }- I ':J `_ <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 .I Utensil washing sink I Store frozen food <br />3 "C <br />Vehicle wash facilities <br />(2 or compartments) , <br />Preparation of food �M Hot & cold water for cleaning �� Toilet & hand washing <br />Store refrigerated food <br />Stolre,f ry food/supplie(sf 4 Provide potable water Overnight parking <br />Adequate electrical outlets <br />C"( <br />Signature of Commissary 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 Date <br />EHD 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008 <br />