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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An.incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: \ . , -z"—"� <br /> Street Address City <br /> 1) License Plate#: .P Z-7 7 4) Year: <br /> 2) Vehicle Vin #: 5) Make/Model: <br /> ! 3) State Decal#: 6) Color: <br /> i VEHICLE Ok/IligER BNFOPINIIATION, <br /> Name: `i C\'I1 1 o' <br /> Address of Owner. <br /> Street Address City <br /> T .t. Mo-.it;: IvCi Ci fGC.iiiiy J' G Ji.rC.G .. v.;C"vi u vv.......v3afy w.. I r vv:�ii�..:.v-:y a: GJC <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 pe it revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: p '► ` <br /> Owner Name: �-p <br /> Site Address: <br /> Street Address City <br /> Phone: ( ) <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 <br /> L] utensil washing sink Store frozen food �� Vehicle wash facilities <br /> (2 or 3 compartments) <br /> I ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washing "IQ Store refrigerated food <br /> ❑ Store dry food/supplies ❑ Provide potable water Overnight parking----�Adequate electrical outlets <br /> PICK fil GO ICE <br /> 7 11�ELdlCREAM <br /> C�.�l. �' • <br /> Signature of Commissary Owner/Operator Date `'- r0=`�' CA 85215 <br /> HEALTH DEPARTMENT <br /> If the commissary/fodd 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 />