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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): 7j4 b <br />Address for Vehicle: „xw 6.--, , ze9, raev,_„&--yi 9ca 4:7 3-- Street Address gi-74 <br />V <br />V ) j ity <br />License Plate #: ,5-v 9/3--y,.2 4) Year: /9e. <br />Vehicle Vin #: /6P4P;zkii<33„Nli/09' 5) Make/Model: 7 ila,z1,1,, 4 4 . <br />State Decal #: A 6) Color: 41,kb/4,61/11,/cier L— <br />VEHICLE2)iNER INFORMAT/7 . <br />Name: i-i- Address of Owner: 733 4/2,14- ,,,,o/- s 1 ..eciet..,), .,._7,5-.- <br />Street Address ,-1-- ,--) 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 office may result in permit revocation and penalties. <br />R (34-) (7)4 0 <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORM ION . <br />Business Name:hZ I <br />g/t,61 <br />I (td J <br />Owner Name: ib,ie.it ILI)/1 il Site Address: ,90 e, ..,,,z,oze,t.:0 /,(..,27.,_ <br />Street Address I- of .) ' 1 City <br />Phone: 007 ) 2M, L./ - <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 />4 Utensil .K" Liquid & solid waste disposalFS washing sink <br />(2 or 3 compartments) Store frozen food P.41 Vehicle wash facilities <br />Preparation of food N Hot & cold water for cleaning &Toilet & hand washing LIII Store refrigerated food <br />Stor dry food/supplies Zi Provide potable water 17 Overnight parking Fi Adequate electrical outlets <br />/l(Nt . ( i / /7- /6.----/ SiOtture of Commissary Owner/Opqf tor çfil‘/ 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 REHS Date <br />END 16-017 <br />7/18/2008 5 of 6 MFPIJ APPLICATION