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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): /9 111V(f/6/i1Q/9 <br /> Address for Vehicle: 3 D C _ 10 r# ST- /7FSBU,0, C/1 9415­6 5- <br /> Street Address City <br /> 1) License Plate#: QO70 Z E 4) Year: 9 9 9 <br /> 2) Vehicle Vin#: 5) Make/Model: Ch/6V <br /> 3) State Decal* 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: F6-_X,4AV1400 %f�i`3 f�S Gfll/D Z <br /> Address of Owner:30-3 E. O77"' 5T. P/ TIsByRr Cf7 9-1{,5-1c5- <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 (CaiCode 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 t ay result If permit revocation and penalties. <br /> � s <br /> S' nature of Vehicle O orator Date <br /> COMMISSARY INFORMATION <br /> Business Name: CENTE/Z <br /> Owner Name: Z) <br /> Site Address: /7/7S IO c5 S ��4LP/// CIV P7 404 <br /> Street Address city <br /> Phone: Z0 0Z 913 —Js (� <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 /> Eg L ?iquid&solid waste disposal Utensil washing sink <br /> (2 or 3 comparbnente) lq4tore frozen food C34ehicle wash fatalities <br /> p <br /> Q Preparation df food C!rHHot&cold water for cleaning r-�voilet&hand washing Store refrigerated food <br /> Lv� <br /> Store food/supplies Provide potable water LJv1emight parking Adequate electrical outlets <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 REHS Date <br /> EHD 1"17 5 of 6 MFPU APPLICATION <br /> 7118/2008 <br />