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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 Narne (DBA): <br /> Address for Vehicle: "rnG�� y �•rDc�7df'1 l� �C <br /> tree Address T —,— city <br /> 1) License Plate#: q 90 4) Year: Ly l 3 <br /> 2) Vehicle Vin #: )_r P 2 k Soo h) Make/Model: <br /> 3) State Decal #: 3) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: -- <br /> Address of Owner: AVV :::�To:L�_ n C—Ak <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 194.295 & 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 /> i4LO(=�� <br /> gnature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: % —SVtaPA _— <br /> Owner Name: <br /> Site Address: ez <br /> Street Address City <br /> Phone: (Z 1 ) 271 1 -17-4 1 _ .--- <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 /> �Utensiil4vas�iquid&solid waste disposalwashing sink Store frozen food C Ve icle wash facilities <br /> (2 or 3 compartments) <br /> — Preparation of food ['I Hoi&cold water for cleaning L !Toil &hand washing ?Adequate <br /> re refrigerated food <br /> Store dry food/supplies /Provide getable v ater ; -I Overnight parking electrical outlets <br /> [?Provide <br /> — A <br /> Signature of Commissary Owner erato 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 ',,IFPU,?.PPLICATION <br /> 7/'8/2008 <br />