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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> 9=59492__Vim# C 1ORMkTILZZI�I� <br /> Vehicle Name(DBA): <br /> Address for Vehicle: nSURIff rM 61 ' S (� <br /> Street Address City <br /> 1) License Plate#: �,Q G Uc lX 4) Year: <br /> 2) Vehicle Vin##: i� T� V, i IMA R�Q 2 522 5) Make/Model: UJ M U <br /> 3) State Decal#: �/� 6) Color: Vy h 4 <br /> Name: �,�' Parr <br /> U i A r6i <br /> Address of Owner: 200 P . <br /> j Street Address city <br /> �! The mob a food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operatin day for cleaning and servicing (CalCode sections 114295 & 114297)_ If the use of the commissary is <br /> ! disc n " ued, the pen-nit holder must notify this office to make the necessary changes. Failure to notify this <br /> offic y result in permit revocation and penalties. <br /> i e of Vehicle Operator Date _ <br /> 01lIIIk1dISQ-A Iii FORltI1 - <br /> �usiness game: � l Q ��d V► r Ul� <br /> Owner Name: Q� I <br /> Site Address: '� S ��r i� ' <br /> Street Address city <br /> Phone: (L q ) 21 - l <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 ❑ ❑' <br /> ),quid&solid waste disposal �2'or 3 comps trn ntrj Store frozen food 'Vehicle wash facilities <br /> P eparation of food ©Hot/&cold water for leaning ��ilet&hand washing ❑ 5tdre refrigerated food <br /> St red y foodlsu Ei Provi a potable water 2/overnight parking Adequate electrical outlets <br /> c \ <br /> ature of orr►t jssa Oiunm er for Date <br /> 7. <br /> aTfFP0i MW <br /> if the commissaryffood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissaryffood establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 Of 6 MFPU APPUCAT10N <br /> 7118/2008 <br />