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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): ,i.e:tedv.4. (V <br /> Address for Vehicle: I.c20) e, 162.,/cedti'-6,71, k. ; I ez.f__ Street Address i ./1- City / <br />License Plate #: 3 z.,g.. 7 Pi 4) Year: j gel , <br />Vehicle Vin #: I G b ;..)Ps. in g„,E3545: 5) Make/Model: - <br />State Decal #: (2, A. ,a1 ,,- 3)6) Color: - <br />VEHICLE VEHICLE OWNER INFORMATION <br />Name: <br />Address of OwVer: /-, d i ,' ----i7v „ 2 4awo 4,t/a- -' d 2 Stree Address / „ 2 -c-- <br />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 office may result in permit revocation and penalties. <br />.)05Q Loc'5 Heirati e_ 7.--7e-- <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION . <br />Business Name: 2 c--, (-- c p.rt C )/ C : 0 ( <br />Owner Name: - <br />Site Address: z ?cc g G__,/ ,.. bk i a V s".i-cc k 4C,v1 cc, Street ddress City ' <br />Phone: ( ) <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 />Utensil washing sink e g Liquid & solid waste disposal yf <br /> <br /> Store frozen food Xi Vehicle wash facilities (2 or 3 compartments) <br />Preparation of food EfFlot & cold water for cleaning X" Toilet & hand washing Store refrigerated food <br />;dry food/supplies <br />. <br />Provide potable water Pr Overnight parking .1X1 Adequate electrical outlets <br />Signature Signature of Commissary Owner/Operator ) 17(5/- ' 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 />7/18/2008 5 of 6 MFPU APPLICATION