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VERIFICATKA OF VEHICLE COMASARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): --reivAAT-ziN <br />Address for Vehicle: -,'441-(C /9--/R roc; L3Llit--1--5:,7-- 0 c 1-0-1,,L-t eq4- _s•-• • 2 . t .% C. <br />Street Address City <br />License Plate #: q p \Am 1 3f, 4) Year: ZO (7 <br />Vehicle Vin #: (IM,9VIU20(M/g) Make/Model: MK r k L <br />State Decal #: 6) Color: Li/ ic\c(k <br />VEHICLE OWNER INFORMATION <br />-.• Name: /lot ( A „ , <br />Address of Owner: 6 i G :(,,.. a_ 24-vc_ Sko k (7, <br />9O 7 .1V? <br />Street Address <br />The mobile food facility shall operate out of a commissary and shall report to <br />operating day for cleaning and servicing (CalCode sections 114295 & 114297). <br />discontinued, the per, it holder must notify this office to make the necessary <br />office may result i --p • rmit revocation and penalties. <br />City to 265 ck _ / 5 63 <br />the commissary at least once each <br />If the use of the commissary is <br />changes. Failure to notify this <br />:---4, <br />r--//:-- Z0/1 __,— ft <br />Signature of Snide Operator Date ' <br />COMMISSARY INFORMATION <br />Business Name: 6 u7:-&-t71F.76R (2>/:)-!-,' )1/: p- .iit-77-A-4-‘a A.) NIA CATERING <br />SUPPLY FOOD AND SERVIC Owner Name: v4-6 Or cRt-C4Tlir • <br />Site Address: 74,,Lf 0 5 g _..) K rip ri ---- \ iLAt _A...4 r(--izr,,,----iy _7:.. - 41400elg rWAY . <br />Street Address <br />Phone: ( 209 q66 0 0-3 0 r-6-2-1 ?_IM j 142____ 0----7:- <br />-208 ...;`'N"'' FtY (209) 466 9000 _ _ <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 />sink Liquid & solid waste disposal Utensil washing IV Store frozen food )(1. Vehicle wash facilities <br />(2 or 3 compartments) <br />ro Preparation of food g Hot & cold water for cleaning Toilet & hand washing X1 Store refrigerated food <br />[K] Store dry food/supplies 1-Provide potable water F-t Overnight parking FAdequate electrical outlets <br />Signature of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local <br />current health permit by signing below. Commissary/food establishment is in <br />County. <br />health jurisdiction must verify <br />Signature of County REHS Date <br />EHD 16-017 <br />7/18/2008 <br />MFPU APPLICATION 5 of 6