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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): -1-6-0DI S (2-0e_v_en- "rx-Dog <br />Address for Vehicle: 2241 L C-1 AAW...4 i b-E 4\ 4,1, Sil .6-1-0 ,K1 C4„, <br />License Plate #: <br />Vehicle Vin #: <br />State Decal #: <br />Street A dress City <br />LIN (,,qb-- %Year: <br />1)42..AD001 't-101155-1 Make/Model: ?rt C_Pc-v-i--- • <br />06\- 6) Color: S'''\ \ k.i-e/v• <br />VEHICLE OWNER INFORMATION <br />Name: -1-7-c,1"712 _ <br />/ <br />Address of Owner: -7:71,- t..-46.-v.. 6; 77,---- 4„.1..._ • ilk '•t,-/7 C <br />Street A ress <br />1 The mobile f4pd facility shall operate out of a commissary and shall report <br />operating d V for cleaning and servicing (CalCode sections 114295 & 114297). <br />discontinu di, the permit holder must notify this office to make the necessary <br />off, e ay sult in permit revocation and penalties. <br />Sti—V7 i2/ i / ) <br />to the commissary <br />If the <br />changes. <br />1 (6 <br />ity <br />at least once each <br />use of the commissary is <br />Failure to notify this <br />SignAtu e of Vehicle Operator Date <br />COMIASARY INFORMATION <br />Business Name: .1-14., A b be y <br />Owner Name: V(cAo P1(..evou(6 <br />Site Address: (9.3V5M ‘0:\-(A (41_ Rt..,e- 44- a _Sitc_AA-10 r\ <br />Street Address City <br />Phone: a q ) <br />I, the commissary owner, can <br />commissary as checked below: <br />1 Liquid & solid waste disposal 4 <br />Preparation of food <br />and will provide the necessary facilities for the above mentioned vehicle at my <br />tensil washing sink <br />(2 or 3 compartments) I I Store frozen food H Vehicle wash facilities <br />Hot & cold water for cleaning n Toilet & hand washing n Store refrigerated food <br /> <br />EZ Provide potable water Overnight parking I I Adequate electrical outlets <br />, <br />Stor? • food/s • inn: <br />, <br />• <br />40491 <br />' 46k - • Siq - ,tize._•••• miss. ew er/Operator Date <br />HEAL - s • i : i , 1.---" <br />If the commissary/food establishment is outside San Joaquin County, the local <br />current health permit by signing below. Commissary/food establishment is <br />County. <br />health jurisdiction must verify <br />in <br />Signature of County RENS Date <br />END 16-017 <br /> 5 of 6 <br /> <br />MFPU APPLICATION <br />7/1812008