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2V'f-RIFICATION OF VEHICLE COMMISSARY <br /> Please ptrf vW'Of information requested. An incomplete application may delay approval. <br /> * kWb ATION <br /> Vehicle Name (DBA): S C ,/_ -5hRC�- <br /> Address for Vehicle: <br /> -'Z&2_C,oN, We StWWSVIfi� n <br /> Street Address City <br /> 1) License Plate#: 5 D3Sk4 4) Year: 9q S <br /> 2) Vehicle Vin #: I67T E3KF�K-35-25'31 5) Make/Model: Cb C V <br /> 3) State Decal #: C I 6) Color: W fl �L`I e_-- <br /> VEHICLE OWNER INFORMATION <br /> Name: fl T . S eti a <br /> Address d Owner. loqqak G C?q 2 <br /> Street Adjress -7 City <br /> J <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, th permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office may result i permit revocation and penalties. <br /> 1 V�3 <br /> Signat—uh of Vehi le OperaRif Date <br /> COMMISSARY INFORMATION <br /> Business Name: we & 601 Cj,�QCI OwnerName: W <br /> Site Address: <br /> Street Address ci <br /> Phone: <br /> I, the co issary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commi ary as checked below: <br /> Utensil washing sink Store frozen food Vehicle wash facilities <br /> below- <br /> Liquid&solid waste disposal ❑ ❑ <br /> ��Hot& <br /> mpartments) <br /> ❑ Preparation of food cold water for cleaning LT I et&hand washing ❑ Store refrigerated food <br /> ❑ Store dry food/supplies Provide potable water Overnight parking ❑Adequate electrical outlets <br /> 7 q <br /> Signature of Commissary Owner/Operator Dat r <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 /> 7118/2008 <br />