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VERIFICAIRN OF VEHICLE COARSARY <br />Please provide all information requested. An incomplete application may delay approval <br />1 - t iti ,,,. -•.is' <br />, q , <br />Vehicle Name (DBA): <br />1 . Address for Vehicle: l - cAc-- -&11r .S1 gc- <br />Street Addrets City —I <br />License Plate #: cA 50 'll,k) ( 4) Year: 2 <br />Vehicle Vin #: c,A,(0.A.A)C4.7 rc(„x;44-11_1 529, 5) Make/Model: <br />State Decal #: 6) Color: <br />. ' 0 t1N-60, -'. "e <br />Name: <br />. Address of Owner. ' 1......=- <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 />office may result in permit revocation and penalties. _ <br />...I a. ...c.o. Z—__ <br />72 7//Y <br />Si•natur of Vehicle Oiserator Date <br />,0 A kosa;41, 7 - , , <br />- Business Name: jyr 1/(ir - <br />, Owner Name: c) ..e <br />, c:•:/ - .e...c _ <br />Site Address: BO/ -1- i-, «,z_z/46a,ee-ZL_ ' i tree! Address City - <br />Phone: (2(2:9_) V- C 7 3 ,?-.) <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 />Liquid & solid waste disposal E Uten'I asi-ng <br />W (2 or :el omportli <br />sink <br />mtnts) 0 Store frozen food 2- Vehicle wash facilities <br />0 Preparation of food LI•iot St cold water for cleaning Ft.; 011et & hand washing Store refrigerated food <br />-1 Store dry food/supplies Provide potable water Overnight parking 7 Adequate electrical outlets , <br />Alir -I —2$i <br />S nature of cornissa Ow Aerator Date <br />,. . :. <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 />.........--. <br />Signature of County REHS Date , <br />— - <br />E.:HD 16-017 6 of 6 <br />MFPLI APPLICATION <br />7/18/2008