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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): rlQ14 Z/17' Address for Vehicle: .2 C' ' j,;) L L C e5-k15 C ?�6 .36 7 Street Address City 1) License Plate#: W6-32-6,-7 4) Year: 2 01 q 2) Vehicle Vin#: 5) Make/Model: TR o' 41,4 E'd 3) State Decal#: 6) Color: �T VEHICLE OWNER INFORMATION Name: Ffi�j— fD C ,� Address of Owner: C 8S Cj,L 11 L6kb7,i5, c4 7,-6367 Street Address City The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this r office mfsul�mr y&Vbcation and penalties. 61 Si nature of Vehicle Operator Date COMMISSARY INFORMATION Business Name: Owner Name: Site Address: / 7 7 S C1/1/j &1 57- p Street Address City Phone: I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: iquid&solid waste disposal utensil washing sink tore frozen food 24 ehicle wash facilities (2 or 3 compartments) 'reparation of food EEHot&cold water for cleaning 2<oilet&hand washing Store refrigerated food D Store dry f /suppliesProvide potable ater Ove rni ht parking Adequate electrical outlets Si nature of Commissa Owner/Operator Date HEALTH DEPARTMENT If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify current health permit by signing below. Commissary/food establishment is in County. Signature of County REHS Date EHD 16-017 5 of 6 MFPU APPLICATION