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VERIFICATION OF VEHICLE COMMISSARY Please provide all information requested. An incomplete application may delay approval. VEHICLE INFORMATION Vehicle Name (DBA): WI 11 NA,J ,5 5 . Address for Vehicle: gre e od el. jhl Cie (too, j-O, p .9'S--,03 License Plate #: Vehicle Vin #: State Decal #: et d dre i city qi2/29k 5 4) Year: c40 i /-7 1/4( 440 c' 7 -r - : / Z-q6 U i a as 6 , - 5) Make/Model S epz 6) Color: 00 IAA' 1 e_ VEHICLE OWNER INFORMATION Name:. pat, 6, 10 i/a id 00'1 a / v_ Zr Address of Owner: 9 e.,), e i • date,' avoit iv 64 Q s- y .2-3 Street Adatess City The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office may result in permit revocation and penalties. /14 / / Signat.fiiure of Vehicle Operator Date COMMISSARY INFORMATION Business Name: COMA j_a6 /14.0060 it k Owner Name: a "Auto Site Address: Oa 71 ST- Plod!, q sr- 3s- - 4--/ ,c,4- Street Address City Phone: 3 5E/ 3/, co I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: Utensil 7-7 washing sink 1 Liquid & solid waste disposal riStore frozen food fl'Vehicle wash facilities (2 or 3 compartments) --/ V Preparation of food 1-(Flot & cold water for cleaning 1-9/Toilet & hand washing [Store refrigerated food z R7Store dry foo• supplies Lrovide table water [4/Overnight parking PAdeguate electrical outlets 2 , Si* nature of Commissary Owner/Operator Date HEALTH DEPARTMENT If the commissary/food establishment current health per ' signing is outside San Joaquin County, the below. ommissary/food establishment 1 local health jurisdiction must verify is in . Signature of County RENS Date EHD 16-017 5 of 6 FAFPU APPLICATION 7/18/2008