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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): R14f. 51S C L. I FO ,l G(W/lll <br /> Address for Vehicle: Co50-1 'Rtzcif;c A,,e- S,6- ly S oCKkov% CA 95'P-0-1 <br /> Street Address city <br /> 1) License Plate#: 93 4) Year: 9el1 <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 6) Color: 12MITE <br /> VEHICLE OWNER INFORMATION <br /> Name: UK, Flolclitiw ; c6�•o+o <br /> Address of Owner: (v SO P4c.1f v<_ S(cjqj S4OCkkl-ate C44 . 9 S- 0 <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 114296 & 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 /> Gam— 7A / 7 <br /> Si nature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: a Ny p C E / I c C 1J <br /> Owner Name: 5194 // U O <br /> Site Address: / 7/ 7 S. G(/✓ 0A1 S T S TO L/{T C gSz O 6 <br /> ZD q Street Address �n11 <br /> Phone: ( /) ' 9 S / <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 8 solid waste disposal ED-Utensil 2or c gashing sink store frozen food � Vehicie wash facilities <br /> (2or9washing <br /> Q'Preparation of food of 8 cold water for cleaning Eafoilet 8 hand washing [tore refrigerated food <br /> tore dry food/supplies rovide potable water E]-6vem ght parking Q Adequate electrical outlets <br /> 3 <br /> Si nature 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 /> EHD 16-017 5 Of 6 MFPU APPUCAT10N <br /> 7/16/2008 <br />