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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): Uh 0 Lpr�.ti C�2u ti (e-, <br /> Address for Vehicle: 'I'� �� vvt k } ,�V'le— <br /> Street Address City <br /> 1) License Plate#: 615-7 4) Year: (a'l�> <br /> 2) Vehicle Vin#: Q- 32k `��5 y ) Make/Model: C pA-� <br /> 3) State Decal #: 6) Color: TIE- <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of wner: <br /> Street Address U 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 /> s 11,4h <br /> Si natur of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: ( p f\,) T—K(C C k E-(JTE(- <br /> Owner Name: <br /> Site Address: 7 s', ae p PJ 2:6:2 ©� <br /> D Street Address City <br /> Phone: ( ) 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 /> Liquid&solid waste disposal t y`t:iensil washing sink <br /> (2 or 3 compartments) Store frozen food Vehicle wash facilities <br /> 'Preparation of food Hot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> Lg-S-'tore dry food/supplies E Provide potable water D<0vernightarking �d q ate electrical outlets <br /> 8,��q 7 <br /> Si nature of Commissary Owner/Operator 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 />