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ECETIED
<br />VERiFICAT[ON OF VEH[CLE COMMESSARroy 3 mit
<br />Please provide ail information requested. An incomplete application may delay approval.
<br />VEHICLE INFORMATION PER d117/-SERICES 41
<br />Vehicle Name (DBA): S , .4 , ,‘„) 1_4, .,z /o 5 .
<br />' Address for Vehicle: //cf,6-) 77,,: (--. • ./, ,. ,e/ -,7 69 - /7 3 6, / ( A s'''')
<br />Street Address City
<br />3 I 5 0 ,—,:, .,41,-- s. 2,,—,4 6,-/i L--)ces,)(
<br />License Plate #: g.4 .„) c-- c D_ (?- 4) Year: /VW
<br />Vehicle Vin #: i --(-., k p ?)Ifi/r- 3 0 5) Make/Model: (/- .e ,>
<br />77/ e.. State Decal #: 2. q ;77 6 6) Color:
<br />VEHICLE OWNER INFORMATION
<br />Name: (,),, 4 ( „, -/ A' ,, -((- , c
<br />Address of Owner: /0 400 7,., .•..-, (, '7/,`r s' ki ") 0 - / 2 (<-.,.4),L 1 .Z.,z 9- c
<br />Street Address City
<br />The mobile foor.i facility shall c.-sperate out of a ccrnmissary and shall report tc.-, the commissary at feast once each
<br />operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is
<br />digne-tntintgpet, filo parertif hrtfrier rt-tr oaf rtnfify fEac mffinga ft re-cmi-ez fkes me.r.aect.try "hang.s. Failure to notify this.
<br />office may result in permit revocation and penalties.
<br />--) -
<br />Signature of Vehicle Operator Date
<br />COMMISSARY INFORMATION
<br />Business Name: 4-6 t CA 5P/ —cv-e , -6 la E406
<br />Owner Name: C., i .LE,
<br />Site Address: l e.)..,0 (P.,A a\ 0 1\1-- f.N.3., h 3 . sc 7 6101- 6
<br />Street Address City
<br />Phone:( coc) z.i _ 2....
<br />l, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my
<br />commissary as checked below:
<br />_
<br />1 Liquid & solid waste disposal \F Utensil washing sink Store frozen food E] Vehicle wash facilities (2 or 3 compartments)
<br />11 Preparation of food st Hot & cold water for cleaning Toilet & hand washing rA Store refrigerated food
<br />1/41 Store dry food/supplies y Provide potable water -' Overnight parking __. Adequate electrical outlets
<br />r• r-
<br />7 —/
<br />Signature of Commissary 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 />Cy, inty..- —
<br />Signature oy County REH§ Date
<br />EHD 16-017
<br />7/18/2008
<br />h/y i (- lit .46 EMD /V , rycj 19:_-)ic-- PU A LICAT
<br />1,21a),'"( 1-1/Z7 . 4ee
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