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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHI_CL_E4INFORIVIATIO.N <br /> Vehicle Name (DBA): o ACOS <br /> Address for Vehicle: _qocaulornia n <br /> Street Address city( <br /> 1) License Plate#: q l Q j -p I E� 4) Year: q <br /> � '06 <br /> 2) Vehicle Vin#: 1�OM21�23W 0 K5) Make/Model: eV <br /> / <br /> 3) State Decal#: CIA 6) Color: <br /> VEHICLE OWNER INFORMATION . ( - a �, c�r�: C� I _ d <br /> Name: U r� S o W Cas 16 r <br /> Address of Owner: 1 T <br /> ramP <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 evocation and penalties. <br /> kiv1V _ I Wi <br /> Signature of Vehicle Operator Date <br /> .bMMISSARY;INFORMATION.. <br /> Business Name: n C �ITrucieNlmh <br /> Owner Name: S A h(AAroi <br /> Site Address: T50 S (A ! 4 I 6t 0 <br /> Street Address city <br /> Phone: (dol) (�' �� 4 <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 /> Utensil washing V/Liquid&solid waste disposal t2 r 3 compartments) ❑ store frozen food Vehicle wash facilities <br /> Preparation of food Ho cold water for cleaning ��Xhancl washing ❑ Store refrigerated food <br /> Store dry food/suns Provide potable water Overnight parking Adequate electrical outlets <br /> Si ature of Co ssa wn erator 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 0`6 MFPU APPLICATION <br /> 7/18/2008 Aftft- <br />