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Page: 2 of 2 02/3/2015 03:19 PM TO:1916452675 :FROM: Jolene PHONE #916 6906243 <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested, An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): i „ n 0 k/d ko ,-- F-00.05 <br />Address for Vehicle: /0 va 0 7-, f,,, 4_,-/...,v s_zi_sl a _173 6 /tar c 4 9, 4 1 <br />Street Address City <br />License Plate #: SA):(ST 3 (i 4) Year: / 9 78 <br />Vehicle Vin #: cp 1. 33- vi3o7 I s' 5 5) Make/Model: (hevac, Le" r <br />State Decal #: c 3 <-10 6) Cplor: <br />VEHICLE OWNER INFORMATION <br />Name: R, , , 7; <br />Address of of Owner: /094,0 7;0;4) e,./,-es /Q., 07 0 -/ 7.. r 6, .. //4 cd 1 rc 32 <br />Street Address City <br />, -r •, --e- . ' • 0 <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 />office may result in permit revocation and penalties. <br />--,,f2s---- 2- </ — /c— <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: <br />.4x)( <br />Owner Name: Name: c6_k ka_.)___\. <br />Site Address: 3 i JO (Liss 0A 6 Km f .L.1.-6) 50,12.,Ab,),\ac ce.,,, 7 s—B, c„ <br />, Street Address City <br />Phone: ( 144 14 ,..c.-- g 4. 3 0 <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 />.:_.. <br />F/1 Liquid & solid waste disposal Utensil washing sink iy1 Store frozen foodSit Vehicle wash facilities R (2 or 3 compartments) <br />[VI Preparation of food PiZI Hot & cold water for cleaning ivi Toilet & hand washing V Store refrigerated food <br />Store dry food/supplies if-I Provide potable water 'VII Overnight parking 'I Adequate electrical outlets <br />,..- <br />,KE---,---1-X--"":• it(2' 0,2- o 3--io <br />Signature of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin Cot, nty, the local health jurisdiction must rify i <br />current health permit by signing below. Commissary/food establishment is in S At ra.viNAA.tik cow ty. <br />4 <br />i <br />tv- Pi- cag ( eci emtikff 2 V45. — <br />Signature of County REHS Date <br />g‘ey+en44.:-...scisr.sreslo <br />EHD 16.017 <br />7/18/2008 <br />5 of 6 MITU APPLICATION