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Jul I I / acEIVIL) <br />:Ju1.21.2017 3:53PM <br />9168758513 p.2 <br />o. 1948 P. 2 <br />1.-tIO 1g-017 <br />7/111q00 0 <br />Received Time Jul. 21. 2017 4:08P o. 1950 <br />5 or MFR.' APPLICATION <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide ail information requested. An incomplete application may delay approval. <br />Date C e Operator Signature of V <br />Date <br />—71 <br />ignatuth of Co REM <br />County, <br />VEHICLE INFORMATION <br />Vehicle Name (111f3A): <br />2/ vk a /69914,o 4,9- g2/ Address for Vehicle: <br />Clly <br />License Plate #: c2 2 03- 3 4) Year; <br />Vehicle Vin #: 5) Make/Model: .A421/ <br />State Decal #:. 6) Color <br />VEHICLE OWNER INFORMATION <br />Name: .) L za, .s <br />Address of Owner: :3 7 roe Way' IC.6-tco e,-44 <br />tree! Address City <br />The rnopiie food facility shall operate out of a commissary and shall report to the commissary at least once each <br />operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br />discontinued, the permit • ust notify this office to make the necessary changes. Failure to notify this <br />office may result id on and penalties. <br />COMMISSARY INFORPAATIOR <br />flYA ria '7223°0 Business Name: Name: <br />Owner Name: CA, j j <br />? <br /> <br />r-3 c44- Wriat <br />Site Address: 3,4 V./3-4/1d cithfr sAfiElsi'k ,/.6 C6 <br />Phone: ( ) 6-6 — ,2 — <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 />FIX Liquid & solid waste disposal (2 or 3 compartments) <br />1 Utensil washing sink 1--1 Store frozen food Ffl? Vehicle wash facilities . <br />Fp Preparation of food fp) Hot & cold water fo; cleaning Toilet & hand washing ir% Store refrigerated food <br />51 Store dry food/supplies Lel Provide potable water -U-Ovemiglit parking 121] Adequaie electrical outlets <br />/ <br />1_47AA-1 6 7-c75—/ 7 <br />Signature of Commissary Owner/Operator Date <br />HEALTH' DEPARTMENT <br />lithe 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 />q6 rol (a+ <br />Siriket Address city <br />, • r re/ • •• • •• rr• <br />Street Address