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( ao�J 4-30—9g1 q <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> r <br /> ERIC E INFORAlIAT10N <br /> Vehicle Name (DBA): V I d - 1�5 11O <br /> Address for Vehicle: 730 s, 64L Q ,4 ,5r` r6YX- Tim " <br /> Street address city <br /> 1) License Plate#: ,OU 4 5 t 6D 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model C' r(/ <br /> i <br /> 3) State Decal#: 6) Color. ,l 7 <br /> r <br /> VEHt9LE—CL NER IF40ORMATION = <br /> i Name: ON a <br /> I <br /> Address of Owner: U M 0 1 (/ (, Q <br /> StreetAddress city <br /> 1 The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> 4 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 /> I�n v4 � U'i--�(--Z 1 (0S-C-) � q. <br /> Signature of Vehicle Operator Date <br /> GOIIAMlSOA'f Y IµN ORMATION <br /> Business Name: L llkJ)114 tlJJ('k 14SIl <br /> Owner Name: <br /> Site Address: <br /> St tet Address City <br /> Phone: (2o J) — ��U - I I <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 /> ffLiquid 8�solid waste disposal Utensil shing sink ❑ Store frozen food ❑ Vehicle wash facilities <br /> // (2 o compartments) <br /> dpreplarabonfood Hot& water for cleaning ©Toilet&hand washing ❑ Store refrigerated food <br /> Stsupplies V Provide ble water ROvemight parking Q Adequate electrical outlets <br /> Sihdziiture of Commi Own a r Date <br /> 1-09,NNW <br /> N <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 REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 711812008 <br />