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Date <br />Store food/supplies <br />VER11FRCAT110N OF VEHICLE COMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE* ilNFORINATION-.. <br />IVehicle Name (DM): <br />I Address for Vehicle: A <br />Street Mims ?s-do <br />License Plate #: /5 791 Year: <br />Vehicle yin 1 i'W.ggpi,2in 5) Make/Model: <br />State Decal #: <br />'E VEHICLE OtliNERARIFORkiliAllON. 1 • Name: (411).a)1(..,,,4_, ,e1 <br />Address of Owner: w(' <br />Street Addr— C11 /4)Fif <br />3 <br />I The mobile food facility shall operate out of a commissary anti shall report to the commissaly at least once each <br />operating day for cleaning and servicing (CalCoole sections 1142e5 114207). if the use of the commissary is <br />discontinued, the permit holder must notify this office to make the necessary changes. Failure to noffy this v <br />office may result in permit revocation and penalties. <br />r e <br />Signature of Vehicle Operator <br />Business Name: <br /> <br />A <br />i, the commissary owner, can and will provide the nec.-essary facilities for the above mentioned vehicle at my commissary as checked below: <br />,Li Store frozen food <br />IX! Toilet 2-. hand washing <br />El Store refrigerated food <br />• <br /> Overnight parking 11K <br />1ALm nEPARTRFAT. <br />If the commissary/food establishment is otstside an Joaquin County, the local health jurisdiction must verity 3 current health permit by signing below. Commissarylfood establishment is in Co Linty. <br />Signature of County REHS <br />EfiD 16-017 <br />111812008 5 of 6 MFPU APPLICATION <br />6) Color: <br />— <br />Sianature of Commis ary Owner/Operator Date <br />E. Liquid & solid waste disposal - <br />"f—i Preparation of food <br />E-T> <br />Owner Name:• -1 Pvc <br />Site Address:201 00 1-‘6.A.-a\ c,14.:Avin Steet Address uukvi <br />City Phone: (2CCI) (01A1,- &i 5 —1 r) 4 <br />Utensil washing sink <br />(2 or 3 comparisnerriz) <br />IA Hot & cold water for cleaning <br />Provide potable water - Adequate elecb-ical Outlets <br />[—) <br />5 <br />Vehicle wash facilities <br />4 <br />Date