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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): M S T L U-9 <br /> Address for Vehicle: 61 S, L- I W T!g P S (r M 0 0 N TIMI N 400S,F, C 1� S-3 I I <br /> Street Address City <br /> �l T� 63 � <br /> 1) License Plate#: � / 4) Year: doll <br /> 2) Vehicle Vin #: •STDY Kap C-X 1350 961(y 5) Make/Model: TO YOTA- sl'ElyN 4 <br /> 3) State Decal #: 6) Color: CZ P A Y <br /> VEHICLE OWNER INFORMATION <br /> Name: ( w J <br /> Address of Owner: 6 S• 1 r R ISD ST, I'R b u N T P I N 14005c= CA q S 3q 1 <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 /> C)Vza120 � �f <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: L-P N TPA-1- �lfi t='�� �17C qSN S <br /> Owner Name: SW AG,,f-7A- C),,IVFk I= r 13 R A-14 111 l4 <br /> Site Address: 2-S q S, r_ i.)!Lf� A V F v l T F A , LD1 , ( A 9 5 2 D <br /> Street Address City <br /> Phone: (209 ) 33 13 862,q 209- 6D3 - 6ocl� <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 ❑ Utensil washing sink Q Store frozen food ❑ Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ® Preparation of food 0 Hot&cold water for cleaning Toilet&hand washing Q Store refrigerated food <br /> ❑Store dry food/ u plies ❑Provide potable water ❑Overnight parking ®Adequate electrical outlets <br /> Signature of Commissary Owner/Operator Date <br /> -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 /> 7/18/2008 <br />