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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): .716;t7,21,,,z cA, 6.1,6v Lct_s ‘,(:0 ii,,t. s
<br />I :
<br />Address for Vehicle: 73r) -i, (7,-, 7 ( 4 ). ,--, ,,,-.31-rXJ,L1-0
<br />Street Address City
<br />License Plate #: 6 .735-38_7_ 4) Year: / 'F-7 .7
<br />Vehicle Vin #: c p L 35 73,336(/6_, 5) Make/Model: cih e v V
<br />State Decal #: 6) Color: e_. ) )-1
<br />VEHICLE OWNER INFORMATION (..D.7.) , -
<br />I Name: 0 .-.'") .Z.,C4.• 6 E3.8 45 e 1 ( 9\
<br />Address of Owner: c,z,(„2 5- 0 /42 77( ,cicX_ ) [c,v) c?-5"os-
<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 />Signature of Vehicle Operator Date
<br />COMMISSARY INFORMATIOM ,
<br />,i ! / r Business Name: (-4,-, //d_,,,, 7i-e9vili tfr-zec.< .,..)c.._ 5' t--k
<br />, Owner Name: 4/a_fe./..),, a a44 Y:0517,-,
<br />Site Address: --7-zr) 4 4/-y--/-2/er ‘5 , 6-71-e-J--_,647 ),-) .
<br />Street ddress— City
<br />Phone: f?c, )
<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 />It- I Liquid„&solid waste disposalUtensil washing sink Store frozen food 1-1-`c en-7-1de wash facilities
<br />(2 or3 compartments)
<br />-----
<br />/ ----
<br /> PrepratiCi-n' of food t- Hot & cold water for cleaning Toilet & hand washing Store refrigerated food
<br />----- -i,r---" , .-- ____
<br />1 t-1 Stor ry food/supplies 1.-/ Provide pot le water Overnight parking IR.A(16-ciute electrical outlets
<br />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 REFIS Date
<br />EHD 16-017
<br /> 5 of 6
<br /> MFPU APPLICATION
<br />7/18/2008
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