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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): <br /> Address for Vehicle: Z(-J L40 S, lkty pov� sick tc of <br /> Street Address City <br /> 1) License Plate#: -7 A i q $�-7 4) Year: /qq6 <br /> 2) Vehicle Vin #: /UTT1q3�,k-gL&5E1 (087,5) Make/Model: (:jA2 L. <br /> 3) State Decal #: r/a L, G. 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: - S7pCk/-v <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 /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 0 L <br /> Owner Name: T?r- 4 <br /> Site Address: _2-44p S . T CS � <br /> Street Address city <br /> Phone: (,pe ) - 00) <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 ❑ Utensil washing sink Store frozen foodVehtcl8 wastt-Faei+i <br /> (2 or 3 compartments) <br /> —i I + )rM.A LATE R I G <br /> ❑ Preparation of food 0 Hot&cold water for cleaning [?/Toilet&hand wash EV!R--e tbrQ(e i e 1YoS8�R CE <br /> 2ay4 S.AIRPORT WAY <br /> 0 Store dry food/supplies Dl<ovide potable water 2-Overnight parking �gtfa�F®�lekcel37�11�ts I <br /> (209)466 soon <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 />