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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): S(N et� <br /> Address for Vehicle: )Q pv S o {-.+C r S}- Lt V c r M D rL <br /> Street Address city <br /> 1) License Plate#: 4) Year: 'ZOocl <br /> 2) Vehicle Vin#: 5 S Lf K PNS& 3915'230 5) MakelModel: Work l\crS r- <br /> 3) State Decal#: 6) Color: grpW tJ <br /> VEHICLE OWNER INFORMATION <br /> Name: Paul P 'isC110 '4-o <br /> Address of Owner: 6y5I MdLtiC CIrCIt LIVerrvtore- <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 ay as in permit revocation and penalties. <br /> / C t�/GteS <br /> 15- 6 - 16 <br /> Si nature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: -14ers kx 4 c S j arca y� <br /> Owner Name: D RYq to r I 1 } <br /> Site Address: j �po Sv4kt, 1-tVCrnn0rc <br /> street Address city <br /> Phone: (qa5) a(a Y - Vt-/b <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 ❑Store frozen food L3XVehicle wash facilities <br /> l-y(2 or 1 compartments) <br /> [J <br /> ❑ Preparation of food Not&cold water for cleaning �-,Toilet&hand washing ElU AStore refrigerated food <br /> ❑-Store dry food/supplies Provide potable water UOvernight parking dequate electrical outlets <br /> S-�-lam <br /> gnature of Commissary 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 Alameda <br /> County. <br /> ��P�1xtL May 8, 2015 <br /> SignatuM of County REHS Date <br /> EHD 18-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />