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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): 86'T' b <br /> (C-61 <br /> jY �Q& <br /> Address for Vehicle: 11(3 TI CR j' A-A,1 C11 9SZQ G <br /> Street Address City <br /> L4 'T S� <br /> 1) License Plate#: 'j r �°— -,�---�� 4) Year: Cj Z <br /> 2) Vehicle Vin#: �,7�� ,( S !cl J)i Die 65iL 5) Make/Model: TI?Lk1- <br /> 3) State Decal #: 6) Color: ij`p(CC)(,j <br /> VEHICLE OWNER INFORMATION <br /> Name: 5 A I C - 6 qS T/1v G ., j2 C I A <br /> Address of Owner: tql.,3 '126.&;14&;14} t j <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 /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: tG (U fj j / 1 raj,( (v -ft✓ <br /> Owner Name: F71:7 <br /> Site Address: F I ( 5 , �V (L 1L Z v c � !Ls , C (l <br /> Street Address City <br /> Phone: ( ) '� ---- * <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> ID/ 121 <br /> Liquid&solid waste disposal �Utensii washing sink <br /> or c 3 compartments) 1 Store frozen food Vehicle wash facilities <br /> 6preparation of food ZHt&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> i [% <br /> Store dry food/supplies Provide potable water Overnight parking [%Adequate electrical outlets <br /> SignAfure 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 />