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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): L_-P Q t3\ -1- p. u N (- <br />Address for Vehicle: -2_32L-1 E h S "X -1. 1V-R cl ( R <br />Street Address City <br />License Plate #: 3\J C-7) --. \ ---)) 4) Year: \ Q\9 I <br />Vehicle Vin #: . 1 CA 131-1(23i-1 K-2 y--- \DOI-0 Make/Model: <br />State Decal #: (pc- 6) Color: Wh tt <br />VEHICLE OWNER INFORMATION <br />Name: P\-y) vcA,\NAM 'c)--Ua\i\C \i U1 Address of Owner: <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 res It in perm revocation and penalties. a .......„, - 2° <br />Signature of of icle Operator Date 1 <br />COMMISSARY INFORMATION <br />Business Name: <br />Owner Name: P•NoNco,._1(\fAY\r`- c)---C)\-\1 Cl u <br />Site Address: Address: 2;3 -Lt.-A .E.P‘-‘ -,---V- -IX' e•- v-j (Av <br />Street Address .1 City <br />Phone: (20) 1----\ Q)--)--- \-2—L-0 - I— <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 />_ <br /> Utensil washing sink „----<iquid & solid waste disposal Store frozen food ,11cle wash facilities (2 or 3 compartments) .,-'- , <br />-1:5reparation of food D-e)t & cold water for cleaning ,121dllet & hand washing tore refrigerated food <br />,- <br />1),Storrdry food/supplies Pt-Provide potable water LA-Overnight parking [equate electrical outlets <br />Signature of Commissary Owner/Operator J Date Signature <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 />END 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008