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VERIFICATION OF VEMCLE COMHAWARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): Mr( lri� (' c S . <br /> Address for Vehicle: ,30 j s <br /> t 0811 <br /> Street Address City i <br /> 1) License Plate#: 4) Year: f �� <br /> 2) Vehicle Vin#: ��Vake/Model: ( ) C <br /> 3) State Decal #: 6) Color: > J 2 <br /> VEHICLE OWNER INFORkIlATION <br /> Name: <br /> Address of Owner: % CA- C <br /> Street Ad re=_s 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 1114295 & 1114297). 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 ermit revocation and penalties. i <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION_ <br /> Business Name: F-r • 'l�.�_ � t: <br /> Owner Name: �� ��_Fir�' �T <br /> Site Address:,-`v Z/1 Y <br /> Street Address / City <br /> Phone: i <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-Liquid&solid waste disposal El Utensil washing sink ❑ Store frozen food Vehicle wash facilities <br /> (2 or compartments) _ <br /> ❑ Preparation of food �.Hot&cold water for cleaning 'Toilet&hand washing ❑ Store refrigerated food <br /> ❑ Store dry food/supplies /i -� P ovide potable water ©Overnight parking }: Adequate electrical outlets <br /> r <br /> Signature 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 /> 7/18/2008 <br />