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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION :fir <br /> Vehicle Name (DBA): LM Mow U <br /> Address for Vehicle: <br /> Tho S' WIMMA <br /> Street Address city <br /> 1) License Plate#: -1-4+14 _ 4) Year: M1 <br /> 2) VehicleVin#: 5) Make/Model: VhEy <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATIONi,. J"To <br /> Name: WAY, M(MOU <br /> Address of Owner: JJVJQY-N <br /> I 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 (CaICode 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. YY <br /> Signature of Vehicle OperatoIFDate <br /> — <br /> Business �rfllh Urgrino, TrU(*Wffh <br /> Owner Name: - QV 4,1 <br /> mlymolov gryis 4 0 <br /> Sit"itldress: (Afflarri(A St <br /> Stnwt Address city <br /> Phone: (,Zoq) 411 - IT41 <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 /> id&solid waste disposal Utensil washing sink <br /> 9 (2 3 compartments) St e frozen food 2/Vhicle wash facilities <br /> Ey� <br /> paration of food t&cold water for cleaning et&hand washing St' refrigerated food <br /> St <br /> 0 <br /> ;C-)ry food/su !as ProVi potable water re Ze Yolernight parking ZAdqate electrical outlets <br /> e 1112-119 <br /> Algi�-Wture of CbmefiisL�, erator Date <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 /> 711812008 <br />