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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): -tet14, ep oko- _ 0,,.../E__Q---,
<br />Address for Vehicle:4g c-,,,-,-, e, -a.,:i.bi>.„), tv,e,,,,
<br />. i Street Address g i ,l' City
<br />License Plate #: 3 ,egg,7 P 1 4) Year: i gel
<br />Vehicle Vin #: .10 b O iC )14;:Z. ft)g-S35zig: 5) Make/Model: elL0.44)24-&-14-
<br />State Decal #: e- A „ILI .,
<br />6) Color: W-111Z-Z2-'
<br />VEHICLE OWNER INFORMATION
<br />,
<br />Name: d.-e-
<br />Address of Ow er: d i, .--4.4.) zzi„,, .di-,,,, , eii i'd 0 1--
<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 />(
<br />.)(3,5Q. Li i'5 He( reca . ,4/ - 7 / t-
<br />Signature of Vehicle Operator Date ,
<br />COMMISSARY INFORMATION
<br />Business Name: 2 a come)/ Ci:a _I
<br />Owner Name:
<br />Site Address: 2 ? 0 0 8-- i,-(0..../ ci: "I buq V ssi-oc k 4G" cc‘
<br />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 h 1 Al Liquid & solid waste disposal [gi was ing sink Store frozen food XI Vehicle wash facilities
<br />(2 or 3 compartments)
<br />Preparation of food E4 Hot & cold water for cleaning g Toilet & hand washing I I Store refrigerated food
<br />I I S r)dry food/supplies
<br />,
<br />X Provide potable water IX1 Overnight parking IKI Adequate electrical outlets
<br />
<br />-- e <ice:)2,- ,A,,,c,,:..-,_ ( 9.--e---4 --,-----i: -1-- Ar, '‘-/ — e; --/ g--- -..
<br />Signature of Commissary Owner/Operator i ' ' 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 RENS Date
<br />END 16-017
<br /> 5 of 6
<br />MFPU APPLICATION
<br />7/18/2008
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