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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): NcAf — <br /> —�5 <br /> Address for Vehicle: • S y i <br /> Street Address city <br /> 1) License Plate#: 56(6 1W 4) Year: ( l!7� <br /> 2) Vehicle Vin #: 1?:3z il/�p) 5SGt1) )Make/Model: G4'wLl P50 Stzfl�� <br /> 3) State Decal #: )D 11 '7-1 6) Color: 13 <br /> VEHICLEOWNER INFORMATION nn <br /> Name: lec (i( 'g-"AS r2.. I <br /> Address of Owner: 20 Lig L-�— <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 (CaICOde 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 /> -7 <br /> SI nature of Vehicle O e a or Date <br /> COMMISSARY INFORMATION : <br /> Business Name: C Lt11,1+C �. E (, '5- <br /> Owner Name. Te'r".%4 T, n� v <br /> Site Address: IW 5 <br /> Street Address City <br /> Phone: ( ) `j2 G <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 /> Liquid&solid waste disposal WI Utensil washing sink <br /> (2 or 3 compartments) Store frozen food Vehicle wash facilities <br /> ® Preparation of food Hot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> Stor�od/supplies Provide potable water Overnight parking Adequate electrical outlets <br /> Sign Te of Commissary Owneri0 erator 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 />