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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): k 0A)Cf l E lk(k{ & (_ PA I yh v �3 <br /> Address for Vehicle: &3q "F'r 5 rt. ''Z CT 9_520 <br /> Street Address city <br /> 1) License Plate #: 676--22 L 6 4) Year: ( Q j.- <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 6) Color: �f- 1 <br /> VEHICLE OWNER INFORMATION <br /> Name: C, <br /> Address of Owner: r!� <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 /> ZLY <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: /I,' Oii �-h T( l N �:'a c l< -- <br /> Owner Name: <br /> Site Address: Z j !!3 . i-L A31-D N ST _ <br /> e"t, r Street Address city <br /> Phone: ( ) .2`� _. ( b <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 Utensil washing sink ore frozen food Q Vehicle wash facilities <br /> (2 or 3 compartments) <br /> 121/preparation of food Q Hot&cold water for cleaning L- <br /> I oilet&hand washing Store refrigerated food <br /> Store dry, &d1suplies vide potable water �vemight parking Adequate electrical outlets <br /> Si nature oYe6mmissary 6wner/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 0f 6 MFPU APPLICATION <br />