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RECEIVED VERIFICATION OFAMJkqftE COMMISSARY Please provide all information requested. An incomplete application may delay approval, HEAL TH VEHICLE INFORMATION PERMIT/SERVICES Vehicle Name (DBA): Address for Vehicle: C2 Street Street Address Ci 1) License Plate#: Gf SIf �f % 4) Year: 2) Vehicle Vin#: y1 % �l f �� c�'!J 5) Make/Model: / �� '� ��-�.�•�%c 3) State Decal #: � 6) Color: VEHICLE OWNER INFORMATION Name: Address of Owner: 6Z 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 114295 & 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 resu n permit revocation and penalties. ign�ture of ehicle Operator Date COMMISSARY INFORMATION Business Name: !' -✓ Owner Name: Site Address: /' _ rte!' • (/ � f`` j;i ,: ,a - - I Street Address /i City Phone: (,SUE) 7& — S j, 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: Liquid&solid waste disposal Utensil washing sink ❑ Store frozen food Vehicle wash facilities (2 or 3 compartments) ❑ Preparation of food ®Hot&cold water for cleaning ( Toilet&hand washing ❑ Store refrigerated food -r ❑ St re dry food/supplies n Provide potable water Overnight parking Adequate electrical outlets �7 Signature of Comm ssary Owner/O motor �' ,'� Date HEALTH DEPARTMENT ` If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify current health permit by signing below. Commissary/food establishment is in County. RECEIVED Signature of County REHS Date -- AIIn 9 Q ZQiq EHD 16-017 7/18/2008 5of6 ENVIROhtAIFTL�&,I'iVLT PERMIT/SERVICES