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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): f\,/&U <br /> Address for Vehicle: 2-440 S /}I Y (bY+ y\3a p ck <br /> Street Address I City <br /> 1) License Plate#: 3T 5 `/--7 2 4) zYear: <br /> 2) Vehicle Vin#: 46L' k{ F3 2-kKS33215')/Make/Model: L <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: CVONG I\JL U <br /> Address of Owner: 2-1 20 M 1CA4A+YA \lJ,a j0C —o AJ p <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 resul in permit revocation and penalties. <br /> J 1 '// 2 -( / 17 <br /> SiSi nat�ur of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: �t�Yh <br /> Owner Name: t � <br /> Site Address: 2,1140 :r 0r3V-- VJ <br /> Street Address City <br /> Phone: (?,M) 2-7-1 — 1- -y I <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 /> 91 Liquid&solid waste disposal Utensil washing sink(2 ora compartmencompartments) Store frozen food Vehicle wash facilities <br /> Preparation of food dHot&cold water for cleaning Toilet&hand washingSto efrigerated food <br /> 19/Store dry food/supplies [Provide potable water Overnight parking Adequate electrical outlets <br /> Ii /Zl � �� <br /> nature of Commis ery 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 />