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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An Incomplete application may delay.approval. <br /> ni <br /> - - M7 i <br /> 041-12' <br /> Vehicle Name(DBA): . <br /> Address for Vehicle:. <br /> Stmet Address City- <br /> 1) License Plate#: ���'l J 4) Year. 2 <br /> 2) Vehicle Vin# ,� ;:. ,(�b1 2�2 3�i5�?.�5) Make/Model: r <br /> 3) State Decal*. 6) Color: <br /> Name: <br /> Address of Owner: <br /> Street CRY <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&1:14297): 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 res - in permit revocation and penalties. <br /> Si nature Vehicle O r Date <br /> 10-1 <br /> �..,. <br /> Business Name: C C C, y C e <br /> Owner Name: S�1 T 1, Am c- ; , ' <br /> Site Address: 3 S?- C , C jp. g 5'i= = S 7 o CK Iry c S�� S— <br /> street maress CRY <br /> Phone:.('-)-'I) <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 /> ❑ Liquid&solid waste disposal ❑ Utensil washing sink �❑Store frozen food Vehicle wash facilities <br /> (2 ora compartments) <br /> ❑Preparation of food Hat&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> ❑Store dry foodtsupplies ❑Provide potable water Overnight paridng Adequate electrical outlets <br /> CK'N GO SCE CREAMI <br /> _.,_C } EN SER.. - <br /> ^ i5 <br /> DateSi nature of Commiss Owner/O erato5TO <br /> - <br /> if the commissaryffood 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 RE HS Date <br /> EHD 16-017 sore - MFPU APPLICATION <br /> 7/1&2008 <br /> 9 <br />