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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> IIVFaRMATI,RC11 IN <br /> IN <br /> N <br /> Vehicle Name (DBA): KL— <br /> Address for Vehicle: �'n S. (1101 d O r I� U. o tb I ' <br /> Street Address City <br /> 1) License Plate#: $?I�0.� 4) Year: 01M J <br /> 2) Vehicle vin#44ff P32MJ D��J$02P 5) Make/Model: C H EV <br /> 3) State Decal#: 6) Color: W h O <br /> VEHICL, O; NERINFORM�AT1ONrN;:. <br /> Name: W 0 <br /> Address of Owner: N"QW �1 PHU <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 /> na ure of ehicle Operafor Date <br /> OMMISSARY;.INFORMATION t w <br /> Business Name: �� � <br /> Owner Name: AWOK V ru-, 1, <br /> Site Address: h S UH i Q V Y( St. ' . <br /> Street Addre s city <br /> Phone: ( 0� ) ' "" I eQI <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 /> /Li id&solid waste disposal 2 Utensil washing sink ❑ Store frozen food [' Vehicle wash facilities <br /> ( r 3 compartments) <br /> Pre "ration of food Ht&cold water for cleaning vi �o'let&hand washing ❑ Store refrigerated food <br /> te dfood/sup e potable water Overnight parking dequate electrical outlets <br /> o ry <br /> Si ture of Coram* wy r/Operator Date <br /> y r € <br /> HEALTH+DE�RARTMENT '" <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 />