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VERIFICAVON OF VEHICLE COW" ISSARY
<br />Please provide all information requested. An incomplete application may delay approval.
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<br />Vehicle Name Name (DBA): Lc, V la Ae, irk --e
<br />Address for Vehicle: / 7 / S 4. 6,7222-7/r-i-/ cl Z(/' i c--)(1) ( Street Address City Zip Code
<br />License Plate #: (2),-ER 949(6 4) Year: k°1RCo
<br />Vehicle Vin #: j_C-3,67P-Z_JAK(4wc(N5) Make/Model: u\e„),rn \d-
<br />State Decal #: 6) Color:
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<br />Name:
<br />Address of Owner: •cizi-1 (a vt t\cC1 -D,e. '5A -0(M-0.r) Cc., 9 5e-oro Street Addrass) City Zip Code
<br />The above-mentioned vehicle shall operate out of a commissary and shall report to the commissary at least
<br />once each operating day for cleaning and servicing [CURFFL 114265 & 114287]. If the use of the
<br />commissary is disqintinued, the permit holder must notify this office to make the necessary changes.
<br />Failure 'he 1.4,Irs office could result in permit revocation and penalties.
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<br />Si t i re sfVehicle Operator bate
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<br />Business Name:
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<br />Owner Name:
<br />Site Address: ad/ _ a
<br />
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<br />Street Address City Zip Code
<br />Phone: (27)":7 ) -_' j Y—,-)-1-7
<br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at
<br />my commissary as checked below:
<br />\VI hi k i il I washi ng snFT Liquid & Solid waste disposal I I Utensil I I Store Frozen Food Provide ice (2 or 3 compartments)
<br />I I Preparation of Food pElectrical Hook-up 7Toilet & Hand washing PrVehicle Wash Facilities
<br />Fl Store Dry Food/Supplies rcwide potable water qrOvemight Parking LIII Store Refrigerated Food
<br />_ _
<br />Signature o Commissary Owner/9 e or Date _ i; , , .,,,:,4,A_, t;: ...,
<br />If the commissary/Food establishment is outside San Joaquin County, the local health RfeeopinvlEy)
<br />verify current health permit by signing below. Food establishment/commissary is in
<br />County.
<br />JUN 2 5 2019
<br />ENVIRONNIEN-IAL HEALTH Signature of County E.H.S, Date DEPARTMENT
<br />El-ID 16-01-013
<br />Page 8 of 8
<br />MFF APPLICATION
<br />5/1 2/2 003
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