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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />V mril(Lt INFORMATION <br />Vehicle Name (DBA): il) 1= <br />1 <br />/ 1 <br />Address for Vehicle:'9.Q e, ahde./' ‘,),,t) i_.-•,-;,) 6 <br />/ Street Address City <br />License Plate #: lic5F/°?6 4) Year: al) a' /? / <br />Vehicle Vin #: 4q,6016gf,04/00/a/ 5) Make/Model: A . /1 <br />State Decal #: 2 # 6) Color: Ai , / L.-, <br />VEHICLE OVV• ER INFORMATIO74 / <br />Name: //.40. ,4414‘e_ / / <br />Address of Ow 1-r: '79'..00, . ' ' 1461,ze ' sttde) &51- q5a2/---- / Street Address y 4-- 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 o / ce may result i permit revocation and penalties. <br />Si.Ure of e Operator Dat <br />C ' • MISSARY INFORMATION <br />Business Name: ts 0\ C. DOCa-C, ct,\ C-Cic Q0CO3:k <br /> <br />(-, „ i• Owner Name: C. • 4 1,- V. - C-4-V \ ‘,. e is\ c ,,,,,e.. s,, . <br />Site Address: afAck) (L. 1.-\ ov--,A irN I, _A_)(7,1„, 6-icoc,4_,ktv-1, c II g 519c) 5 Street Address J -,1 City <br />Phone: (;x\) Li( i.- • /-1 5 ---/ 0 <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 />washin KI Liquid & solid waste disposal 0 Utensil g sink I I Store frozen food g Vehicle wash facilities (2 or 3 compartments) <br />n Preparation of food / M Hot & cold water for cleaning Toilet & hand washing I I Store refrigerated food <br />n Store dry food/supplie ' iZ1 Provide potable water Overnight parking M Adequate electrical outlets <br />1 . <br />/ <br />O. <br />Signature of Com issary Owner/0 rator Pi Date <br />HEALTH DEPARTMENT <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 RENS Date <br />EHD 16-017 <br />7/18/2008 <br />5 of 6 MFPU APPLICATION