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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)_-A�_Lwt;, e(OU �( ( <br /> Address for Vehicle: 4440 1C1 ; A Nev <br /> Street Address City <br /> 1) License Plate #: Z}CiE L(lOU 4) Year: <br /> 2) Vehicle Vin #: 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: 1721`- CC N v 206 <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 /> �USQf)rk OCW 'dar <br /> - q <br /> Signature of Vehicle O erat r Date <br /> COMMISSARY INFORMATION <br /> Business Name:C1/1 - I � �Ui C �f hG �LWL� <br /> Ii���, � lil�� < <br /> Owner Name:2 0 <br /> Site Address: )-L40 Com. 11�1 60— Wllk C <br /> Street Address City <br /> Phone: (` ))� '-qUNVID <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 foodVehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food /Hot&cold water for cleaning EI/Toilet&hand washing Store refrigerated food <br /> ❑ht re dry food/supplies 12Provide potable water Overnight parking Adequate electrical outlets <br /> 1 , k 12-412W3 <br /> Signature foe 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 IQI=nr::11l1 /If D <br /> County. I U.%JL.1 V <br /> L. <br /> SEP 2 8 2015 <br /> Signature of County REHS Date <br /> LINIVIKUNMENTALHEA61-1 <br /> PERMIT/SERVICES <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />