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4 n0833 <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An Incomplete application may delay approval. <br /> Vehicle Name (DBA): <br /> Address for Vehicle: !PC? Jy L,U'rYL Q t XQ(JN-TAI N H D Jd L <br /> Sheet Address CRY <br /> 1) License Plate* meg 2 4) Year. .Z 0 )'� <br /> 2) Vehicle Vin#: 5) Make/Model: � L <br /> 3) State Decal#: L!zt 6) Color. 12 V <br /> VEMIC�E.OXII�Ii�R-:INFQRM/�TI®N ;; ;._ " <br /> Name: <br /> Address of Owner: N PLO Yn ja-s p <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 /> Sig nature of Vehicle Operator _ Date <br /> ,,C©MMIS000I NFORMATION,' <br /> Business Name: /Ar� C1►/ liaryk b✓i° ��L C —-_ <br /> Owner Name: <br /> Site Address: (Li L+ar°rrk0�� Cao � TS—/ <br /> street Adds city <br /> Phone: (-- ) LY14(9 6 ---- <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 /> 0 Liquid&solid waste disposal -E] Utensil washing sink Store frozen food Vehicle wash facilities <br /> (2 or 3 compartmerds) <br /> {aPmp&-edmefiood ©'H"o�&-cold water for cleaning ,Toilet&hand washing GStore refrigerated food <br /> Store applies E31provide potable water EOvemight parking PTAd equate electrical outlets <br /> Signature of Commissary Owner/Operator_ Date <br /> HALtt D PARTM_ <br /> If the commissarylfood establishment is outside San Joaquin County,the local heal u iction/rnust verify <br /> current health permit by signing below. Commissary/food establishment is in O <br /> ung,. t4 I ( <br /> Si ature of County REHS Date <br /> EHD 16-017 5 0f6 MFPU APPLICATION <br /> 7/18/2006 <br />