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r'40J,,,17syy- 1162s Q <br /> VERIFICATION OF VEHICLE COISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): Yn�)( ftp )' S-H i°r✓e ICE (f 0 . <br /> Address for Vehicle: <br /> Street Address V city <br /> 1) License Plate#: L4 I-- K I Z Z 4) Year: <br /> 2) Vehicle vin #: S335C lD I ZBK20224-�) Make/Model: / I�AILGn <br /> 3) State Decal #: 6) Color: J{ate <br /> VEHICLE OWNER INFORMATION <br /> Name: I I,A1V 1,, S tfJ G� C(�/nJ LLc- <br /> Address of Owner: Z�D9 W . n4 &/\/ Sv/kC OD S7ZG�G <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 /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: IZ/N A-r,D / 5 km A+2 <br /> Owner Name: \J t eno Qr F0 N* <br /> Site Address: Z4 1, 11,_ ')t ivc.*9 / /2-JJ <br /> Street Address City <br /> Phone: (ZO�) -7 - 3 5-6-7 <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 /> Liquid&solid waste disposal ® Utensil washing sink Q Store frozen food ❑ Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ® Preparation of food ®Hot&cold water for cleaning ®Toilet&hand washing ® Store refrigerated food <br /> Store dry food/supplies Provide potable water ®.Overnight parking ®Adequate electrical outlets <br /> Signature o o a Owner/O erator 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 I <br /> 7178/2006 <br />