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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> K Mr- <br /> ,N�IFORMI�T_ION���'.•y�� y, ;��` �<»';�<w r��a� .�r��: k s � -�rt �.� <br /> �UEH <br /> a._�.._ k..b. a <br /> Vehicle Name (DBA): �- <br /> Address for Vehicle: �- <br /> Street Address city, <br /> 1) License Plate#: 51 44 N oa �4)), Year: o�/L�(Doo <br /> 2) Vehicle Vin#: 1(ji7E (a(�18�,TV'�76 13 5T Make/Model: �=l NI C. <br /> 3) State Decal #: 6) Color: (,LJ Y& e <br /> .•� ', �` ..'° <br /> Aribegfp�' " '4t'rr�t-M+': .igau. �t.; <br /> VEHICL_EOWNIER INFORMkTION ,-+ <br /> Name: 'j' C- I E ti Lr <br /> Address of Owner: 14 f-�. R y2E 2 � /,qy 6DE <br /> Street Addfess 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, th-e-permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office ay res tir�per it revocation and penalties. <br /> -- - ;� /, <br /> Si ature o icle Operator Date <br /> ,COMMISSARY,,INFQRMATION� ; <br /> Business Name: 717 <br /> Owner Name: `� l <br /> Site Address: tU <br /> Street Address City <br /> Phone: ( - (f6-/Z 22 a7/ /7�ZZ <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 /> Liquid&solid waste disposal tensil washing sink ❑ Store frozen food ehicle wash facilities <br /> (2 or 3 co artments) <br /> reparat'on of food of 8,cold water for cleaning oilet a hand washing <br /> 1:1 Store refrigerated food <br /> tore food/supplies [�,P ovide potable water aoVernight parking Adequate outlets <br /> Signature of Commissary Owner/Operator Date <br /> HEALTFiDEPARTMENT MRS 4;� �tl r •� �` Y; <br /> S, <br /> :.....,. .c `T`+ Rau <br /> c.-{��A�rsvraaw.usec �-.u.. ,x.:: <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 cr 6 MFPU APPLICATION <br /> 7/18/2008 <br />