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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): ^5IVC4 A] Cl- /S � Z.L L _ <br /> Address for Vehicle: ,2Z2—F— I&RS'T GIS- Z�� <br /> Street Address City <br /> 1) License Plate#: Ata IG I r j 4) Year: 199 q <br /> 2) Vehicle Vin #: ,5) Make/Model: 'j(3(L�) C j n <br /> 3) State Decal #: CLQ 6) Color: (-:�s 2..Ft=-1J <br /> VEHICLE OWNER INFORMATION <br /> Name: - C ' <br /> Address of Owner: 7-227- 6-- 1)1/l1 . 5-r -51—&(k7—QC. C4 F-6 2(2e <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 /> discontintae the--permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office a iii�ermit revocation and penalties. <br /> Si at r of Ve le Operator Date <br /> C&411iSARY INFORMATION <br /> Business Name: WU <br /> Owner Name: <br /> Site Address: 71Z <br /> .5 ulUte1J S✓_ S7-0C.krcTLJ( '14- <br /> 207 Street Address city <br /> Phone: ( ) 1219 -,5. <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 /> i <br /> quid&solid waste disposal D Utensil washing sin21 k <br /> (2 or 3 compartments) Store frozen food ETVehicle wash facilities <br /> 0-1:1reparation of food of&cold water for cleaningToilet&hand washing lfStore refrigerated food <br /> E186—re dry food/supplies 'Provide potable water Overni t parking Adequate electrical outlets <br /> x Z//,/ <br /> Signature of Commissar 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 />