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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�.��SCc It, a ctrl <br /> Address for Vehicle: 1>- <br /> Street Address city <br /> 1) License Plate#: �Qc�� � _ 4) Year: l q P) <br /> 2) Vehicle Vin#:jj!, 3 .nJ6S35o � <br /> ! ZZ Make/Model: (li1L <br /> 3) State Decal #: 6) Color: Y\ i} <br /> VEHICLE OWNER INFORMATION <br /> Name: C <br /> Address of Owner: y\ 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 (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 /> S t 0 c x C) C 0 Y\Z c"l e- ? G/ Z:S") 12s, 15 <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: CA UFa N ser iC-el <br /> Owner Name: N` <br /> Site Address:A40 9. NyQTTWDA <br /> Street A dress City <br /> Phone: ( ��) �� <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> Utensil washing sink <br /> Liquid&solid waste disposal Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) A �" n <br /> Pre aration of food �ot cold water for cleaning �oilet&hand washing FU�11�bd fabd E <br /> �CD ANDS R\,"ICE <br /> tore d food/supplies lies rovide otable water verni ht arkin Ad �j���t fTQJ9tTe'N./A <br /> dry PP P 9 P 9 <br /> ��T"d_CK�ON, CA 9520 ;:'.r.. <br /> T'(209)466 9000 <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 />