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a ' <br /> 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: pllfvQ")M 11� 0(� <br /> Street Address city <br /> � <br /> 1) License Plate#: 4 Year:�� ) / <br /> 2) Vehicle Vin #: l C-1CYl 5) Make/Model: C yW-\j <br /> 3) State Decal #: \A 3��y 6) Color: y�1 <br /> ,VEHICLE OWNER INFORMATION <br /> Name: 1 �+(w <br /> Address of Owner: 'D 3 Q,C\\ �`'� La G- 9'S 33C_;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 revocio, a nalties. <br /> L / <br /> Signature of Vehicle O erato Date <br /> COMMISSARY INFORMATION <br /> Business Name:L 64CUla Ar n r I band ,S <br /> Owner Name: <br /> Site Address:.2c1 I 0 1 S (� <br /> Street Address City <br /> Phone: <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 food Vvehiclei <br /> {2 or3compartments) ORNIA CATE ING <br /> rr paration of food �o &cold water for cleaning Toilet&hand was n9Sr Fefri t SE VICE <br /> 440 S.AIRPORT WAY <br /> Store dry food/supplies Provide potable water ��ernight parking > A�QKTl tj(I8lV9 @6 <br /> 4 (209)466 9000 <br /> Signature CommissaryOwner/Operator Dat <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verity <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 />