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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): E et v u k ens e -... <br />Address for Vehicle: I.2),--6 \ g' or i (W.)c) W1Li rbc. K.:mit, <br />Street Address City <br />License Plate #: L1/2 v‘ci 7)`21 \ 4) Year: V10 -1 <br />Vehicle Vin #: 3.Ei v. F5-1 w ov‘ 33 0 6 Lig 3 5) Make/Model: Orley /Ni w <br />_ - 3) State Decal #: 6) Color: 1,.;) h <br />VEHICLE OWNER INFORMATION <br />Name: ."Rat-n 0 n C---itet.--,,,-e_ in:, <br />Address of Owner: \ ,,73 \ s • vq 't Vsat;-. V1/4,6k--- S tv.crial-bin <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 />iflice may result in permit revocation and penalties. <br />° • ae.jci il.cl'L o eS" 5' 7.4)714 i, <br />:Signature of Vehicle Operator Date <br />'COMMISSARY INFORMATION <br />Business Name: E k , <br />Owner Name: 'clam o vl C--kje vy-e.ro <br />Site Address: \ .''3 \ s . w i ksot-i kitv 0-.1 tbc,t,=-1-cw-) <br />Street Address City <br />Phone: (-Loci ) 2.q2 - '2.-olci <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 />3 Liquid & solid waste disposal 1K Utensil washing sink JA Store frozen food 1 1 Vehicle wash facilities (2 or 3 compartments) <br />lil Preparation of food rgFlot & cold water for cleaning 5Toilet & hand washing XI Store refrigerated food <br />X Store dry food/supplies K1 Provide potable water gl Overnight parking E4 Adequate electrical outlets <br />Sivature 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 RENS Date <br />r , <br />EHD 16-017 <br />5 of 6 <br /> <br />MFPU APPLICATION <br />7/18/2008