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VERIFICATION OF VEHICLE COMMISSARY <br /> RY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: 2 ' " G <br /> Street Address ( City <br /> 1) License Plate#: 5'P'7 7 IJ C 4) Year: CJl <br /> 2) Vehicle Vin #: t�NfZ�" !j!c r5) Make/Model: % t a/? f i4 )try <br /> 3) State Decal #: 6) Color: �AZrat Tt~ <br /> ,VEHICLE OWNER INFORMATION. <br /> Name: 1Z 211M i'air-7, <br /> Address of Owner: - 0:(. J G l aV C' Y ( f1 (/- � ta5 3 . <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 /> ,,;�L--✓_,c; L17— � 06 — J -�— 20(6 <br /> Signature of Vehicle Operator Date <br /> .COMMISSARY INFORMATIONI, =" <br /> Business Name: jFOP�1 ' G�I'ERIN(7 'iii. q !)klj&L .D-1J7 Vit, 7 <br /> Owner Name: t pj17�TI -I <br /> Site Address: /gyp Sz% <br /> Street Address City <br /> Phone: ( ') 4W,r1U71 ' <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 <br /> (2 or J compartments) L_y'Siore frozen food vehicle wash facilities <br /> ❑ Preparation of food Q Hot&cold water for cleaning ❑'foilet& hand washing Store refrigerated food <br /> D'S-tore dry food/supplies ❑P'�ide potable water ❑Zenright parking Adequate electrical outlets <br /> �>L- U - <br /> Signature of Commissar Owner/Operator Date <br /> HEALTH DEPARTMENT - <br /> . . <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verity <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 0l 6 <br /> 7/762006 MFPU APPLICATION <br />