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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE IN <br />Vehicle Name (DBA): <br />l, <br />1--1001eiCit eA <br />Address for Vehicle: 30c), i\ t .•z61 Traug / Not o'-'2.i)i <br />Street A dress City <br />License Plate #: 4) Year: <br />Vehicle Vin #: 5) Make/Model: <br />State Decal #: 6) Color: <br />VEHICLE <br />Name: <br />OWNER INFORMATION <br />l it <br />Address of er:4D5- )V4,11141Aps 41(Vt( \Ala , lufb billlo <br />Stree Address <br />The mobile od facility shall operate out of a commissary and shall <br />oper-ii ng for cleaning and servicing (CalCode sections 114295 <br />, _o t i nue the permit. holder must notify this office to make the <br />i - y tat in permit revocation and penalties. <br />ic <br />ill <br />5)44/11 <br />City <br />report to the commissary at least once each <br />& 114297). If the use of the commissary is <br />necessary changes. Failure to notify this <br />Signa'ure of Ve icle Operator Dat <br />COMMISSA6r 1Wiliki1 <br />Business Name: i 0 <br />Owner Name:A <br />Site Address: l'4,..S- T' j 13(i Eview -Ti- bO45 <br />Street Address City <br />Phone: (kb) 36-3 - Oq3s <br />I, the commissary owner, can and will provide the necessary <br />commissary as checked below: <br />il Liquid & solid waste disposal Utens washing sink <br />(2 or 3 compartments) <br />Preparation of food 0 Hot & cold water for cleaning <br />Store dry food/su lies Provide potable water <br />facilities for the above mentioned vehicle at my <br />Store frozen food 0 Vehicle wash facilities <br />0 Toilet & hand washing LI Store refrigerated food <br />0 OverT/ght parking 0 Adequate electrical outlets <br />0 (1 (-)- eil A A <br /> <br />Iva re .of 101,VT ...sa er/O•erator Date <br /> <br />AtkiLL, t4.:-f A .. <br />-lad% .114rWir 1' ' <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 />EHD 16-017 <br />7/18/2008 <br />PAFPU AAPUCATION 501 6