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VERIFICATION OF VEHICLE COMMISSARY <br /> .Please provide all information requested. An incomplete application may delay approval. <br /> w., <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> StreetAddress city <br /> 1) License Plate#., 4NM51;?O — 4) Year. <br /> 2) Vehicle Vin#: I RW I IM 01-00,115) Make/Model: <br /> 3) State Decal#: VA 6) Colo <br /> ! VEHICLE <br /> oo <br /> Name: Wyk 'Mvp) 41;'71 <br /> i Address of Owner: <br /> vnu oiI <br /> .5204 S �t N(/�ton <br /> Street Address J 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 114296 & 1142971_ If the use of the commissary is <br /> :discontinued, the permit holder must notify this office to make the necessar'y changes. Failure to notify this <br /> office mW result in permit revocation and penalties. <br /> Si nature of Vehicle Operator Date <br /> Cv�OMMISSARY <br /> INFORMATION <br /> Business Name: <br /> W <br /> Owner Name:__ <br /> / Or <br /> Site Address: W7 S 61111WMIM st Nouon <br /> E <br /> Street Address city <br /> Phone: (Zoq) -ZJ1— J-TZfl <br /> 1,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked bel <br /> E�J/Uqulcl&solid waste disposal Utensil/Utensil washing sink Store frozen food Vehicle wash facilities <br /> (2 <br /> Z 3 compartments) <br /> Pre ration rabon of food 0 cold water for cleaning �E�/ ot W&hand washing E] Store refrigerated food <br /> nStorea <br /> Store d food/su i s Providepotable water O/vennlght parking Zdequate electrical outlets <br /> t 10/10 <br /> Si4Kature of Co anis OwnerlOperat& Date' <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 /> EHO 16-017 5of6 IVIFFIJAPPLICATION <br /> 711812008 <br />