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RECEI VED <br />JAN 23 2018 VERIFICATION OF VEHICLE COMMISSARY ENVIlin <br />-NMENTAL H Please provide all information requested. An incomplete application may delay approvaRERAimsER E./11TH <br />., <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): & L_ fi/t MFR. E <br />Address for Vehicle: 31//1 Al ley A v6, sro iirr-0/6 e... it 9 3-.2_ e 4.• 5 Street Address City <br />License Plate #: 17( /46 '16 / 4) Year: ,Z b 1 7,-- <br />Vehicle Vin #: i (10i 6W. i 3 2.5-c-- Pi 151 0 14 5) Make/Model: LA I-TRPt kV /..-(T7 ) ;' <br />State Decal #: 6) Color: 1./ <br />1' <br />VEHICLE VEHICLE OWNER INFORMATION <br />Name: c ,61 T-n 4 / fun G (ir,3 iy1/4 t\I Gf'77M1 <br />Address of Owner 3 ii ( ( Al 11 1Z Y` /9 (it: ,570d4.-Tb rd, 6144 ?._6‘ ‘,2,04 <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 p?naly_e_s.e 6 s <br />/ / ci,,, „,:c., 6 u y NA - r'f---.' <br />cpt-c.7 /in Y C7crz IP(..z4-c -7 yfribl 0 / — 0 q - za <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: w/V/Cyd cif 7---- --g//06 77_, v c k. 6.' 6 iu -7- R., <br />Owner Name:s/t/z ix gd ,e 77 -k fi zi a <br />Site Address: / 7 /7 ,s-. Li AI / 0 /V c y / sr) azTo t y c 4- 9 5,02 OS <br />g 0 7 Street Address 1 City <br />Phone: ( ) c7,? ? <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 />/ ',.V (i4 Utensilwashing sink m,-- t-- Liquid & solid waste disposal FVf Store frozen food 12:li Vehicle wash facilities (2 or 3 compartments) <br />F-41‘paration of food {at-lot & cold water for cleaning al-cil-et & hand washing Ijstore refrigerated food <br />E-- Frg;re dry food/supplies itz /Provide potable water gi‘ernight parking RAdeguate electrical outlets <br />/ <br />Sigrtature 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 />) <br />EHD 16-017 <br />5 of 6 MFPU APPLICATION <br />7/18/2008