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VERIFICAWN OF VEHICLE COVISSARY <br />Please provide all informaiTn requested. An incomplete applica may delay approval. <br />,. VEHICLE INFORMATION, , • <br />Vehicle Name (DBA): =_/Ni t G-Lt .E...-z— 6 4t_F--,e 'I <br />Address for Vehicle:-7 4f0 7-- Los 8,44)0.Q i-, 33.So3 <br />Street Ad ress City Zip <br />License Plate #: ,Priq g/$-7/7 4) Year: / 97 <br />Vehicle Vin #: i 6-1-Cgtet‘C2VM..8(031 5) Make/Model: sonoma__ <br />State Decal #: 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: <br />Address of Owner: 70--- xj,12,10,,,,(ir__ Av./ ket5 ,,..a/rt_422 () • (-7-)3 3 j-- <br />Street Address City Zip <br />The mobile food facility shall operate out of a commissary and shall report to the commissary at least <br />once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of <br />the commissary is discontinued, the permit holder must notify this office to make the necessary changes. <br />Failu e to notify this office may result in permit revocation and penalties. <br />S ature of Vehicle eratoi Date „,.., . MMISSARY INFORMATION <br />Business Name:.Thi 91, I:4, <br />i--,t___ Owner Name: A lq <br />z( . , <br />Site Address: -NO. tijeo:5 74- ,7- 6--f--- :,,5 geo-7,5- et_ 3 <br />Street Address City Zip <br />Phone:0,1 1316 o f t i <br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at <br />my commissary as checked below: <br />LII Liquid & solid waste Wtensil washing sink LII Store frozen food Fill Vehicle wash facilities disposal (2 or 3 compartments) <br />Preparation of food Z--Elot & cold water for cleaning dToilet & hand washing Store refrigerated food <br />Store dry food/supplies in Provide potable water Overnight parking LI Adequate electrical outlets <br />6C ///// /a <br />Signatu of Commissary Owncperafor Dale <br />ALT I I DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must <br />verify current health permit by signing below. Commissary/food establishment is in <br />County. <br />Signature of County R.E.H.S. Date <br />EHD 16-013 <br /> Page 8 of 9 <br />MFF APPLICATION <br />8/17/2007