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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): �_376 <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate#: ^50%5,� �7 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: Vo fd(-� <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: s ( l LE 1U LS G1/1 h2 <br /> Address of Owner: COC;o l y;r��J Cr j � �CAcity <br /> Street 4 dress <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 /> j�_ ma12-ao- <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: VAI 0 C f�l&16 -Fy Q<,k_ C-LY0 7 6- <br /> Owner Name: IW6 E G� <br /> Site Address: 7 U j U Av ( <br /> �Y. Street Address ' City <br /> Phone: ) 1, �� .6 <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 /> 0 quid&solid waste disposal R Utensil washing sink <br /> (2 or 3 compartments) ore frozen food gehicle wash facilities <br /> M/Preparation of food riot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> Store dry food/su plies DProvide potable water �/Overn ght parking [Adequate electrical outlets <br /> r' <br /> Signature of Commissari 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 />