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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> lclk-. <br /> 75, <br /> R, <br /> Vehicle Name (DBA): La' -t-or\6-i Ta- <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: D ZrJ sa 4) Year: A <br /> 2) Vehicle Vin5) Make/Model: C_fle Vq <br /> 3) State Decal#: 6) Color: <br /> -'R. IFT <br /> Ni <br /> :p <br /> Lt C.WNtpt NF RMPION 1 <br /> Name: a6 C-1 <br /> Address of Owner: !n- m Clk a5 <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 ip, <br /> permi revocation and penalties. <br /> � <br /> X_ 2 <br /> Signature ofVehicle-'Operator Date <br /> COMMISSARY L.INFORMATION <br /> Business Name: 6 ft v\I'ss ctyy <br /> Owner Name: Ljjj)o () <br /> V- - <br /> Site Address: ZU3 'S 4k/ 61 15 Vo Lo 01' <br /> StreefAddress city <br /> Phone: (-Loci) <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> MI'Liquid&solid waste disposal El utensil washing sink(2 or 3 compartments) © Store frozen food Vehicle wash facilities <br /> �Preparation of food Z"Hot&cold water for cleaning TrIT101let&hand washing ;M1`S`*t*0r_e efrigerated food; <br /> 01*S'tore dry food/supplies Provide potable water MKOvernight parking Adequate electrical outlets <br /> �ign;ilure of Commissary Owner/Operator Date <br /> HEALTHS 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 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />