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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): <br /> Address for Vehicle: .27D5- Uf P AE //E 5 Oc IJ Q 'OL/ <br /> Street Address city <br /> 1) License Plate#: 7R 313 0 4) Year: I q 37 <br /> 2) Vehicle Vin#: 5) Make/Model: G jJ6616LET <br /> 3) State Decal#: 6) Color: L) ( I f TC <br /> VEHICLE OWNER INFORMATION <br /> Name: o5 6k0ANDE2 E EZ <br /> Address of Owner: 2705 0. 19&P1fljE Il tle. ST c 95a o <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 & 114287). 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 /> N X31/ /-' <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: (/ /p/tl TER 11L16 .Ue C EN TE/Z <br /> Owner Name: 7—/96,00 <br /> Site Address: /717 ,5. /OR/ ST 5TDCJ,TO�t1 611 6:R 6 � <br /> Street address city <br /> Phone U9 ) C (F -S /z <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 LJ Utensil washing sink(2 or s compaMrerrb) E31torefrozenfood Vehicle wash facilities <br /> QKreparation of food [!J/Hot&cold water for cleaning Toilet&hand washing tore refrigerated food <br /> lq-slt�ore dry food/supplies rovide potable water Eq 6O emight parking 0 Adequate electrical outlets <br /> / <br /> Signature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissarylfood 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 18-017 5 r»a MFPU APPLICATION <br /> 7/1W008 <br /> J <br /> f/) <br />