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VERIFICATION OF VEHICLE COIlWIScA;,v <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFQRMATION r4 'r M1 „� "� "aE �� N�� ;°3i k 1 <br /> _.. .... r. a•...�"!'$i F r:�b�.r.; k d _ 1��,yay'' r <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Address36q-5 <br /> � � � Ct�s1) License Plate#: � 4) Year: <br /> 4) <br /> 2) Vehicle Vin #: _TL52,43014' 5) Make/Model: (�;��✓�" <br /> 3) State Decal #: 6) Color: <br /> .- -. .:W t rt 9 kHA k .r.,xa,r..p t t L <br /> VEHICLE OW gJR,I;NFOR- kk� 4t .i r..L I Mllhu � M <br /> �r <br /> Name:Address of of Owner: 11,3 hi-D -`-L, [L't'j" 041- <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 (CaiCode 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. i <br /> Signature of Vehicle Operator Date <br /> CMIVIISl�R1It�FnR�VIA1`NOt�yru k r �� 4 µr,t�� lat t I L,k <br /> tt�k Yi�u rvr t tF I h .�"'(� t I I it t X1,1 L e .c n �P 3'w ;t,- wk <br /> Business Name: " '� <br /> I 2( CGS �Y I I� rGt VJCr v 16-C 411,61 t <br /> Owner Name: riWAY(] <br /> Site Address: S_M t WIr <br /> Street Address city <br /> Phone: ( 244W - bk <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 X19/`Vehicle wash facilities <br /> (2 0 3 compartments) 19 <br /> //Vehicle <br /> of food of&cold water for cleaning le &hand washing,. , Store.refr�gerat�d food :_. <br /> Store dry food/supplies rovide potable water vemight parking =:i - quate;electrical pts lets <br /> 'C S.AIR^CRT WAY <br /> STOCKTON, CA 95=U6 <br /> Signature of Commissary Owner/Operator Date / _ (209)466 �0oo <br /> s k'N 'r''"i.I r u Z. <br /> NEALTH_:!DEPARTMENT r t Lr_. � ��� �7 � �a ¢��� t Ing t2J� <br /> rxW,! tlt�+". �'.kL"hn... ! C ---,M ,x '. <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 RE HS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />