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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> 1JEI-IIL.LE�NF�9R➢ll' _T_ON� .x.�b Yak'.)v`°u."_'r3.�,�-�2`s.1 ri"' ..ter` `!� s°�.._ ,'-.�3 Ir_.z" G.a�.,,:•t.:.,- ..� '.�'�.>.s <br /> Vehicle Name(DBA): NO( R I C r C C A S <br /> Address for Vehicle: �J —�LC P/Z <br /> Street Address City <br /> 1) License Plate#: A'k 3 L,1\-\�A 4) Year: 400 ( <br /> 2) Vehicle Vin#: JCnCHCp3S-291jilpo5,5- 5) Make/Model: cy-fryx0),L�-7 ✓A <br /> 3) State Decal* 6) Color: <br /> Name: I AIICn N <br /> Address of Owner: o L,f/(t/%L-?2 �tAM TGA <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 & 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 result in permit revocation and penalties. <br /> r <br /> Signature of Vehicle Operator Date <br /> COMIVIISSA 1fJF4RTJDNs�"• -'.�� � _ 4'r��.�,._.� <br /> Business Name: Y o c <br /> Owner Name: In - ' <br /> Site Address: '3Sr!%� c Eat/ &' -D r7o (' J of S-:� S� <br /> Street Address city <br /> Phone: ( ) <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 -L3 Store frozen food ,W Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑Preparation of food Hot&cold water for cleaning Toilet&hand washing 'E Store refrigerated food <br /> ❑Store dry food/supplies ❑Provide potable water -E1 Overnight parking ]Adequate electrical outlets <br /> �CX N GO ICE CREAM <br /> Signature of Com miss Owner/O erator Date - ` ; n K oNi CA 215 <br /> HEALTH DEPARTMENTi s }se n <br /> MAN W as ` '; v ^5 <br /> ��•:.r_xw . . .<.±-,-•tt..n 6..,�a_�:`�..o:ft R, a�-" <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 RE HS Date <br /> EHO 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 _ <br />