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E Utensil washing sink <br />12 or 3 compartment:4 <br /> <br />I <br /> <br />Store frozen food Vehicle wash facilities <br />VHot & cold water for cleaning hand washing 7 Store ieingerated food <br />Provide pOtiible water Ovel night paiking ,V1equate electrical outlets <br />_ <br />periator rjate <br />i'iEALTH: DEPARTMEN L <br />, I , <br />_ <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify current health permit by signing bolow. Commissary/food establishment is in County. <br />EHD 16-017 <br />7/10/2008 64) j 4 c <br />MFPU APPLICATION <br />- ic ) A-ikort% s T <br />(D./ Gif) 5 of 6 \1CCSC 4:? erg <br />, Business Name <br />I Owner Name <br />I <br />Site Address: <br />Phone <br />ST lo r 4.2/-7 <br />7J L/_<-7J <br /> (4ii% (14' <br />City <br />SSARY INFORMATION <br />Street Addross <br />I i, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />Signature of County REHS <br />solid waste disposal <br />Preparation of food <br />7 Store dry food/supplie::, <br />Si nature of CommIssar <br />Date <br />VERIFICATION OF VEHICLE COMMISSARY <br />r,(z csui <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): <br />Address for Vehicle: 7/7 1Q e IA/-4 ) t 7 <br />Stroat Address City <br />P/CdYB 4) <br />31L91212,23±5_4Thyp5 ) <br />Year <br />Make/Model: <br />6) Color <br />614}1 <br />v77/ <br />1) License Plate #. <br />,1 Vehicle Vin g. <br />i <br /> 3‘ State Deca <br />I Address of Owner /0?tio_. <br />I VEHICLE OWNER INFORMATION <br />Name. /')ej-/ t i`e:/tti i---/- -7 <br />_ — , <br />' Street Address <br />ft&Ltiii6, LC ( <br />City <br />_ <br />1 The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br />operating da for cleaning and servicing (CalCode sections 114296 & 114297). If the use of the commissary is <br />discontinued permit holder mus <br />! office may t in permit <br />t <br />revocation <br /> anotif <br />nd <br />2 <br />i70272024 Failure to notify this <br />mar Vel-role Operator Date