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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> � 11 w�s1 <br /> AVE wens 0cuu secs u�amv�.+m�uav> <br /> Vehicle Name (DBA): <br /> Address for Vehicle: 0 <br /> Street Address City <br /> 1) License Plate#: �� � � 4) Year: <br /> 2) Vehicle Vin#: Lj�L.3�— ��) Make/Model: 9 <br /> 3) State Decal#: 6) Color: <br /> r-''s� ' ^.a''sg�-�r�"�ax5l":.a�nrn .��. .,,.��ni`w,.i �,'u4• ?+4: F.. +,rX�T�xC's; {f., r�`�;''�„r';-� .,,tea-`' ;-: <br /> nuEHI,CLEflWIRINFORMA;TIOTV' Vg <br /> 42 <br /> � � � �� <br /> Name:` J! Ka 7(,— p2 <br /> Address of Owner: ( (,v / U J Z <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-nay result in permit revocation and penalties. <br /> G-- & // l� <br /> nature of Vehicle Operator Date <br /> ZZ <br /> `•'- `' m} <br /> Business Name: <br /> Owner Name: <br /> Site Address: �/JsGc, <br /> Street Address city <br /> Phone: Q Cil <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 /> &��-id& olid waste disposalnsil washing sink ❑ Store frozen food ehicle wash facilities <br /> (2 or 3 compartments) <br /> reparati of food of&cold water for cleaning Ilet&hand washing El store refrigerated food <br /> tore ry o /supplies n�vide potable water [y^ Nght parking equate electrical outlets <br /> �–�'V mac' <br /> i nature of Commissa Owner/Operator Date <br /> k r �. ��Frya�,le �-y' <br /> 11, E�` D--PARFT EN <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 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />