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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION yy /, <br /> Vehicle Name (DBA): ; avv c(-E ( '� G� (VG c -� R 1 ( 6�f P-, <br /> Address for Vehicle: CE) b '-1 C ^ -UaC � Q4 26-377 <br /> Street Address City <br /> 1) License Plate#: �� / -meg- 4) Year: © � <br /> 2) Vehicle Vin #: y �1� C5 / 2 �.� kCSO° ) Make/Model: <br /> 3) State Decal #: 6) Color: ((L <br /> VEHICLE OWNER INFORMATION <br /> Name: L,IFIo 705E u- p© r-E CAdvEZ <br /> Address of Owner: ( � 7j(-ai, C4 <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 y result in permit rev cation and penalties. <br /> -� <br /> 912, <br /> p c <br /> Stnnature of Vehicle Operatbr Date <br /> COMMISSARY INFORMATION <br /> Business Name: l -I-rrf IdG -R 64 ck CEP(MA <br /> Owner Name: <br /> siwr,„U��SS: 17 1 �5 U fv i G rv' ` 5 c?(e-�4- 10 4 e, <br /> 1 { C( Street Address City <br /> `' <br /> Phone: ( ) a S , 5/ <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 /> Liquid&solid waste disposal Eq-Utensil washing sink <br /> (2 or 3 compartments) tore frozen food Q Vehicle wash facilities <br /> `� rep r-anon of food Fiot&cold water for cleaning 0 Toilet&hand washing O'Store refrigerated food <br /> {' Stored food/supplies G _P_rovide�iotable water Overnight parking Q Adequate electrical outlets <br /> i <br /> 81.2 3-`Z/5 <br /> Si na ure of Commiss� Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food/food estahNehrnent is auts Glc San Ioaquir, County, the !coal health iurisdic}jnn mi�c}vre rlf i <br /> ry I _.._ . 1 <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 APPLICATION <br /> 7/18/2008 <br />