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VE-RH 'E'A ION OF VEMICLE COIMMUSS RY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMAT[ON <br /> Vehicle Name (DBA):• 1 o'gQ(J-6(-) i ^•�_ \ ! C if\C� <br /> Address for Vehicle: Sos f--r) V i r �r t - �• <br /> Street Address city <br /> 1) License Plate#: 4) Year: 20 f C! <br /> 2) Vehicle Vin#i �5) Make/k/lodel: <br /> 3) State Decal #: 6) Color. <br /> VEHICLE OWNER INFORMATION <br /> Name: 1 "-ac-, t C (' Y <br /> Address of Owner. ' <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 /> EiC�f7_� d E <br /> Signature of Vehicle Operator Dater b <br /> COMMISSARY INFORMATION <br /> Business Name: I—q COP'2 130111 <br /> Owner Name: f, I -S• r • V- <br /> Site Address: �� <br /> Sweet Address Citta ' <br /> Phone: (2C9) ' FP <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below:eEr � <br /> Liquid &solid waste disposal 2 utensil washing sink tore frozen food El�—Vehicle wash facilities <br /> (2 or 3 compartments( <br /> reparation of food Hot&cold water for cleaning �oilet&hand washingStore refrigerated food <br /> Store dry food/supplies �2, PrQovide potable water Overnight parking Adequate electrical outlets <br /> naturAfCommissary 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 cf County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />