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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br /> <br />Vehicle Name (DBA): Lc. LA1. C V\Oar Cq\Ck , <br />Address for Vehicle: (c) 2_0 S. c---f.&,C&M(2).(\-0 --1/4-- Lcz-- c.R <br />Street Address City <br />License Plate #: c„cocA VIZ 1 4) Year: <br />Vehicle Vin #: 1 CI C \--\ p 32J\IVR(091 Make/Model: (....\VE..\) (2.0 itA-- <br />lq State Decal It: I cPg l C A 6) .olor: <br />VEHICLE OWNER INFORMATION <br />Name:...--e--6-i----2,- /2 C)1-"----- .-----_,,e'-C <br />Address of Owner: (2-913 0 A\c-.4-ItU)D-Y gP <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 permit revocation and penalties. <br />-1? —1. CA_ <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: 'CAN L..c- \.., -Pc Z. , (TA <br />Owner Name: \e PrCV 0 \f \or NcvyC L C-Irk( c CA <br />Site Address: (.02n c C .,,.0CcTh aNC\CD E5 \-- La:S. <br />t'Veet Address City <br />Phone: (2,0) 2 z A --3,4_ ,.) a C) 0\ Lao-3 S?.:_e; \ S-- <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 />t Liquid & solid waste disposal (2 or 3 compartments) <br />I I Utensil washing sink 7 Store frozen food V Vehicle wash facilities <br /> Preparation of food 15ZI Hot & cold water for cleaning Toilet & hand washing 1/4,0 Store refrigerated food <br />NK1 Store dry food/supplies I I Provide potable water 1(1. Overnight parking V Adequate electrical outlets <br />— \ 9 <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 />County. <br />Signature of County RENS Date <br />EHD 16-017 5 of 6 <br />MFPU APPLICATION <br />7/18/2008