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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): - t rs <br />Address for Vehicle: I LIi 0 0 uo ‘.,... %1‘4,00 / V-7..... Le,f.,\ t, CA 9 <br />Street Address City <br />i SeCt,34-#'61.C.11 <br />License Plate #: 38 0 g?, 9 5-i-t 4) Year: <br />Vehicle Vin #: . ..._ A . , _ *4 ) Make/Model: "i2v, A ose,A ..-Ni-ci_LA4A- _ <br />\ 3) State Decal #: 6) Color: <br />VEHICLE OWNER INFORMATION <br />(Name: -k\Ata '---e_s.cN.- <br />Address of Owner: 1 q ion 14.) tit u:,s\b, Lii_a_4( ri Li`ii, 1 C k is- Lij 7_ <br />Street Address City ,A' <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 <br />offi ay esul in permit revocation and penalties. <br />Signature of Vehicle Operator Date <br />, COMMISSARY INFORMATION <br />Business Name7-0. % A I s <br />Owner Name: <br />Site Address: I Li 9. NO (.3 0_4 tA ze3‘t_c_tic„..1 Vt.. L tnA. i C Ct; 1 c- in-_ <br />Street Address City <br />Phone: (c2.0 9) 30 /6 id ) <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 />3c10 6,...,444._ a <br />1— Utensil washing sink o ht ,a, <br />rLiquid & solid waste disposal Ti Store frozen food Vehicle wash facilities (2 or 3 compartments) • _.,.... . <br />Ti Preparation of food - Hot & cold water for cleaning Toilet & hand washing Store refrigerated food <br />n Store dry food/supplies ' Provide potable water Ti Overnight parking [ 1 Adequate electrical outlets <br />, / <br />, Sig ature of Commis Owner/Operator 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 />, <br />EHD 16-017 <br />7/18/2008 <br />5 of 6 MFPU APPLICATION