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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE iNFORIVIATION <br />Vehicle Name (DBA): <br />Address for Vehicle: 730 .3 /e. /2 /C. S 4 <br />Street Address City <br />,. <br />License Plate #:gic7 q3b015.727 4) Year: /9 7e <br />Vehicle Vin #: Zp 43s7 60 „.. 5) Make/Model: Chk/y _ <br />State Decal #: 6) Color: b( We <br />VEHICLE OWNER INFORMATION <br />Name: c <br />Address of Owner: °3z_7(3 s-- /v7 &I r-F---a ,, <br />Street 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 />2 -C e L - ' 9- -' - - e-2 <br />/ <br />-7 e Sig ature of 'ehic e Operator Date <br />COMMISSARY INFORMATION <br />Business Name:, <br />Owner Name: <br />cs / <br />Site Address: 73Q <br />Street Address City <br />Phone: (2.0 ) 177e-77 7-° (1;.// 7/ / 7z77/ <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 />lik<r-Zashing sink iquid & olid waste disposal Store frozen food 2,--Whiare-Cash facilities <br />(2 or 3 compartments) <br />Preparati of food ILI-1<'8---;cold water for cleaning 7.-T-olrer& hand washing Store refrigerated food <br /> to e 'dry foop supplie C' ovide potable ater 14...>efErght parking laciet tf-J.L-ie.:lectrical outlets <br />i <br />- • A a PI 'a rd% PI' // 7 h- ‘ <br />Signature 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 REHS Date <br />EHD 16-017 <br /> 5 of 6 <br /> <br />MFPU APPLICATION <br />7/18/2008