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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all informolon requested. An incomplete applica,,,on may delay approval. <br /> A <br /> 'j" _0 <br /> Rz U <br /> R ', A <br /> Vehicle Name (DBA): co <br /> Address for Vehicle: l <br /> Street Address City ' 61 SLS-7-ip Code <br /> 1) License Plate#: M95M, 4) Year: <br /> 2) Vehicle Vin Make/Model: <br /> 3) State Decal #: 6) Color: <br /> i`;t4, IIkk* 2.i11RO 11 '4� <br /> P.; 4AA,,1,*.`-.-.f <br /> Name: Q Yd M W-0 VVY11- ) -tb L__ <br /> Address of Owner: 1102, <br /> Wa LTD (&,-t b+DE44�n C61 <br /> Street Address City Zip Code <br /> The above-mentioned vehicle shall operate out of a commissary and shall report to the commissary at least <br /> once each operating day for cleaning and servicing [CURFFL 114265 & 114287]. If the use of the <br /> commissary is discontinued, the permit holder must notify this office to make the necessary changes. <br /> Failure to notify this office could result in permit revocation and penalties. <br /> OL V1 C�a &02 a 5� IgI / <br /> gignature of Vehicle Operator Date <br /> Business Name:0-0 <br /> Owner Name: 9�m I f1A doy— -1 4'P vr)s <br /> Site Address: (-rl 10 �5F. 5toclmpn (_10, _ <br /> Street Ad s City Zip Code <br /> Phone: (2oq ) /-.7"T , V4,5/ <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at <br /> my commissary as checked below- <br /> 'T — <br /> iq,id&Solid waste disposal below: <br /> sink E] Store Frozen Food a.?f6<1de ice <br /> (2 or 3 co rtments) <br /> reparation of Food a4�ectrical H up Lr tet&Hand washing [��ehicle Wash Facilities <br /> ;ectrical0H <br /> :Ltzz!ao Dry Food/Supplies rovide potable water �,might Parking ❑ Store Refrigerated Food <br /> iZggnature of Commissary Owner/Operator Date <br /> t0i <br /> T.,XV <br /> A4 <br /> -2 <br /> If the commissary/Food establishment is outside San Joaquin County, the local health jurisdiction shall <br /> verify current health permit by signing below. Food establishment/commissary is in <br /> County. <br /> Signature of County E.H.S. Date <br /> EHD 16-01-013 Page 8 of 8 MFF APPLICATION <br /> 5/12/2003 <br />