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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): Z. A 1---- X'<..) //4 2c ' / <br />Address for Vehicle: <br />Street Address City . <br />License Plate #: 2/ ef_3 F6-1 4) Year: —.---C <br />Vehicle Vin #:/k/C,Z(iz.)674,/s2/6,93?5) Make/Model: (--4—jqg I <br />State Decal #: /g 6) Color: 4nct.K('-evkia-cicl <br />VEHICLE OWNER INFORMATION <br />Name: <br />Address of Owner: , A/9i us r6n-L c t 642 r Street Address . City <br />The mobile 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 holder must notify this office to make the necessary changes. Failure to notify this <br />office may result in permit revocation and penalties. <br />`C('-; <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION , <br />Business Name: <br />Owner Name:e96; t. e _ le t • )(Lola? <br />Site Address: Lp '1,0 c.) a( rk lot it) 5 V- (5 Loo, (A <br />c -Street Address City <br />Phone: (20() .7a — (..,,.. .5 ] <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 />Utensil washing sink Liquid & solid waste disposal Vehicle wash facilities (2 or 3 compartments) I I Store frozen food <br />I I Preparation of food Hot & cold water for cleaning Toilet & hand washing ii Store refrigerated food <br />I I Store dry food/supplies I I Provide potable water I Overnight parking I i I Adequate electrical outlets <br />( -1014t/ M71 1 — I ), - I (67. <br />Sigri'attfte 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 />County. <br />Signature of County REHS Date <br />EFID 16-017 <br /> <br />5 of 6 <br /> <br />MFPU APPLICATION <br />7/18/2008