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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): L.0 R Q LF TN-E WINGS <br /> Address for Vehicle: 73D S . ST . STDG Com! 952t) <br /> Street Address City <br /> 1) License Plate#: 4RGg32(D 4) Year: 2017 <br /> 2) Vehicle Vin#: CRI 1782-07 5) Make/Model: VA a.1 i=D <br /> 3) State Decal#: 2(::;I '9 2n 6) Color: BL_Lks IPE D <br /> VENICE_ E OWNER INFORMATION. ... . <br /> Name: REAN,,J A4 M I C.++ 2o? 7f <br /> Address of Owner: (0311 gEELSR ST. STOGlCt �rJ c}k GI5201 <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 ma result in permit revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY.,�NFORM „TON. - <br /> Business Name: ccR r Gc.0 Lc>G$ <br /> Owner Name: <br /> Site Address: a �' <br /> Street Address City <br /> Phone: (2� Y6 t� 2 <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 /> quid&solid waste disposal nsil washing sink � store frozen food ehicle wash facilities <br /> (2 or 3 compartment) <br /> eparation of food UH6t&old water for cleaningE�Rrl Ifet&hand washing ❑ Store refrigerated food <br /> 12 orre food/supplies Ovide potable water fight parking equate electrical outlets <br /> Signature of Corn issa 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 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />