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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> -xw� A'. r �pwrsmvyxs�s:C- 10, x� c %�.&7�E er'k fe�''�f ;; �'trtir�'ia,3`'ar u,E 1,s'FIRWy"2,�.O <br /> UEHIfiCLE INFORM�1`TION " t r r � z � �` w <br /> Vehicle Name (DBA): UA <br /> Address for Vehicle: -J'no E. CflldjorfllGS • D <br /> Street Address (nt C�TyO 2, <br /> 1) License Plate#: ��Vl�ll�� 4) Year: u11M <br /> 2) vehicle vin#:1�jGIfip32M°I D332 8� 5) Make/Model: �Hy <br /> 3) State Decal#: ('i� 6) Color: <br /> 4 11 ✓f f"i:Y`� y..., iL".�tl St i M1. S � .: 1 <br /> �/ HICLE OWNER INFORMATION <br /> Address of Owner: V210 V a l` yl <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. _lq ``/I / <br /> L� V 1 r9 <br /> na ur- of ehlcle O era or Date <br /> OMNIISS/ARYFINFORIVIAT'ON""" <br /> Business Name: arI h F .r. IC' Aar <br /> Owner Namero� <br /> Site Address: Th I Cali OI` <br /> Street Addre s city <br /> Phone: (' 01 ) ell <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> ;Zire� <br /> id&solid waste disposal Utensil washing sink ❑ Store frozen food �hicle wash facilities <br /> ( r3compartments)'ration of food Zt&cold water for cleaning �o'let&hand washing ❑ Store refrigerated food <br /> `' vi potable water Overnight parking Adequate electrical outlets <br /> d2 ar r <br /> r/Opera r Date <br /> IIE/01N4®EPARTM_E_NT <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 5of6 MFPU APPLICATION <br /> 7/18/2008' <br />