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VERIFICAllitN OF VEHICLE COMOSSARY Please provide all information requested. An incomplete application may delay approval. : Vehicle Name (DBA): <" Address for for Vehicle: 02-( 7ri1).5- Street Address City License Plate #: 7257.i7 3:2 1) Year: iqqq Vehicle Vin #: 41--(), P57 9 m 2 kj-g60 -6 Make/Model: C;r0f State Decal #: 6) Color: V/Z/Kli-e, "1 Name: Erandoh 1 aq t- r Address of Owner: (/ M14‘)/457 Or Ldr - Street Address City The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is 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. ....,- -7 /Ole/1ff Signature of Vieticle Operator Date 1%. Business Name:1 6' /4-1-711 -r-f/ ( Owner Name: Jr/ rzr id Ame4 6 Site Address: 7//ç -S-G,G7/-ke,00 --C7 - Z zh (-/ Street Address City Phone: 01)9) 33 V — )c7? I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: F Liquid & solid waste disposal Utensilwashing sink 0Store frozen food 5-Vehicle wash facilities (2 or 3 compartments) Preparation of food pHot & cold water for cleaning p-Toilet & hand washing Store refrigerated food 'Provide Store dry food/supplies potable water P-Ovemight parking p Adequate electrical outlets , ZIA., ...'K ../ .4._ : &1-1-(8' Sign -r of bommissa • r er/Operator Date If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify current health permit by signing below. Commissary/food establishment is in County. Signature of County RENS Date EHD 16-017 5 of 6 MFPU APPLICATION 7/18/2008