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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): 40— Z Z S <br /> Address for Vehicle: 3 b 3 57. S L/f l-f0f IW Z,17 9s8/il- <br /> Streett Addfws City <br /> 1) License Plate* O Irl ?�5 5 4) Year: 9F6 <br /> 2) Vehicle Vin#: 5) Make/Model: 6 17IC- <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: E8 COSI-A <br /> Address of Owner: 3 3 _ 57— 1-- <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 mault in permit revocation and penalties. <br /> fn! n t9rk4 y// /�// 7 <br /> natUY6 of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: uAlloAl C G /1 6 i— C GE/U'TE/Z <br /> Owner Name: <br /> Site Address: S 50cklt fa -ff gra to <br /> -2 D`/ p Sbeet Address City <br /> Phone: ( ) A / g�—S q( 6 <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 /> quid&solid waste disposal L y 12 or 3 it washing sink store frozen food 19/vehicle,wash facilities <br /> (2or�eo asking i <br /> ®Pcparation of foodtt&cold water for cleaningoilet&hand washing Store refrigerated food <br /> tore dry food/supplies vide potable water [5 Overnight parking Adequate electrical outlets <br /> �v <br /> Si a ure 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 <br /> County. <br /> Signature of County REHS Date <br /> EHO 16-017 5 of 6 MFPU APPLICATION <br /> 7/16/2008 <br />