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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): L- <br /> Address for Vehicle: 2 1-() 5. '0A9-VL9�T- <br /> Street Address City <br /> 1) License Plate#: '� 65 2�-)3 4) Year: C� 916 <br /> 2) Vehicle Vin#: 2-a7 W 5) Make/Model: C)—tu V <br /> 3) State Decal#: 6) Color: (j)kA\:-\,6 <br /> VEHICLE OWNER INFORMATION <br /> Name: MftA Slo VAN <br /> Address of Owner: LILt C(1 <br /> Street 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 permit revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: ( , �( <br /> Owner Name: <br /> Site Address: z-914L) _ <br /> Street Address City <br /> Phone: (`?ej) I — 17 0 <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 /> LiquidI—I&solid waste disposal Utensil washing sink tore frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> WL-J r eparation of food Hot&cold water for cleaning �oilet&hand washing Sore refrigerated food <br /> Store dry food/supplies Provide potable water �(Overnight parking Adequate electrical outlets <br /> Si n�ture of Commissa Owner er 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 />