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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION , <br />- A <br />Vehicle Name (DBA): <br />M o YP n t T aIll'''. 0" <br />Address for Vehicle:r ' cut Li ? Sacl (AMV IrrE-O, SA k. L. 452g <br />b t ree Address City <br />License Plate #: 5 E 0 I too 8 4) Year: I Cil '7 <br />Vehicle Vin #: ( 1:::° L 3j g3i 0 ze,s\--5-) Make/Model: <br />State Decal #: 6) Color: uk) <br />VEHICLE OWNER INFORMATION , <br />Name: 0 0 St 0 OA 60( 0 h. oek <br />Address of Owner: I 5, 5 s . 50.c_rarae 71,1.1 0 &i_. j 0 el; (A ot 6 g1-1- <br />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 rmit revocation and penalties. <br />..1 / ...—.... 1 3' l D 5 ) o 9 i <br />Signature of A jcle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: Cid i S54YY <br />Owner Name: 1 - IT 06tidtk <br />Site Address: <br />Street Address City <br />Phone: (20( ) 1 a 9, —357 <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 P<::uid & solid waste disposal I 11-‘;:wash facilities <br />(2 o compartments) I I Store frozen food <br />I IPre aration of food I 1,1 Hot & cold water for cleaning I VToilet & hand washing Fq<rerefrigerated food <br />FP Store dry food/supplies FP R/Cide potable water Efr<Tnight parking L-dequate electrical outlets <br />7 '—'11 ct <br />Signaturalof Commissary Owner/Operator Date <br />H EALTH 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 RENS Date <br />END 16-017 <br />5 of 6 <br /> MFPU APPLICATION <br />7/18/2008