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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): -Z C YY( ftC FO N C. <br /> Address for Vehicle: 376 QC(., STOG U N C q�S�bS <br /> street Address city <br /> 1) License Plate#: ,5 Y S7 2(P 4) Year: 1972 <br /> 2) Vehicle vin#:G Pz 33 Z 2 2`1 5) Make/Model: C H C V R-0 LE r <br /> 3) State Decal#: 6) Color: t j " 1 Te <br /> VEHICLE OWNER INFORMATION <br /> Name: EC ir Ll r( T(AJEZ. U3152t) <br /> Address of Owner: 37/,,lo &(A/Ul)Y PU. 5 p fS <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 /> offiemay result in permit revocation and penalties. c <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: AJ-p dAT69iAJis jWttiCK CEtJ &/2 <br /> OwnerName: 6ALVAllOL -o <br /> Site Address: ( In s. N(DfO .ST-. STDG , T0AJ CA- c5oZ,O <br /> Sliest Address city <br /> Phone: ( ) <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 /> /, <br /> Liquid&solid waste disposal i�1Uil washing sink <br /> (2 er J eempadmerds) �to2 frozen food Vehicle wash facilities <br /> 9pre'aration of food &cold water for cleaning Toilet&hand washing Store refrigerated food <br /> Store dry food/supplies a Provide potable water Overn ght parking Adequate electrical outlets <br /> a <br /> Signature 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 18-017 5 of 8 MFPU APPLICATION <br /> 71182008 <br />