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VERWIC T ION OF VEHCLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval...... <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): -11 i&(jC �1 G�OJL•�ml l� <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate # l L 4. Year: 1� <br /> 2) Vehicle Vin #: tt "�i�'�tiQ h� 7jhl� Make/Model: (7M C.. <br /> 3) State Decal #: 6) Color: ha&k,�' <br /> VEHICLE OWNER INFORMATION <br /> Name: . �� - <br /> Address of Owner: �j j vl ?,�L1GVy I-OtA .,✓ T)✓ C ; <br /> Street Address city <br /> The mobile food facility shall operate out of a commissary and she!! report to the commissary at least once each <br /> operating day for cleaning and servicing (CalCode sections 'I 14295 & 114297). If the use of the commissary is <br /> discontinued, the permit holder must notify this office to matte the necessary changes. Failure to notify this <br /> off- a ma result in permit r vocation and penalties. <br /> Si nature of Ve iicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: GI I�Of ec, Su I <br /> Owner Name: c, _ S <br /> Site Address: 2 U 4-�- f S�0 lL <br /> Street Address city <br /> Phone: (Zucj) 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&solid waste disposal L;Ktensil washing sink Store frozen food dVehicle wash facilities <br /> ,,-�// l2 or 3 compartments) <br /> I�Preparabon of food E�/Hot&cold rater for cleaning ?,Toilet&hand washing 2"Siore refrigerated food <br /> tore dry food/supplies Provide potable%vater 210'vernight parVig '. [Z/Adequate electrical outlets <br /> Signat eooiommissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health.urisd'iction must verify <br /> current health permit by signing below. Commissaryhood establishment is in <br /> County. <br /> 9`• <br /> Signature of County.REHS Date <br /> � r <br /> I <br /> EHD 16-017 6 of,3 89,=PLI APPLICATION <br /> 7/1812005'' <br />