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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> ;VEWCLEINFOfflmpm <br /> Vehicle Name (DBA): CIAS5ic D06S <br /> Address for Vehicle: CT- <br /> Street Address Cfty <br /> 1) License Plate#: y&-fl'!5:Zjo 4) Year. <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Der-at#: 6) Color: <br /> VEHICLE JOWNtRINFORMATION . .. ..... <br /> Name: Lt= LLE P <br /> hl)11-LI/E7TE LL <br /> Address of Owner: /13_57 GI-CIONYXC OC OILJ., Gd 9520j(- <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 may resultin per revocation and penalties. <br /> "-I xtat4 �ITll? <br /> Si nature ehicIdOperator Dat <br /> 'COMIMISdArRYINFOR'NiATION <br /> Business Name: 64AR04 CAJ6 T-RUCk eg5AJrZF! <br /> Owner Name; <br /> Site Address: / 7(7 S , e-elVloAj 577 —57-6(f KID4g(5 <br /> ZDT Street Address city <br /> Phone: ( ) ,2 �ff- ,5-q 1 � <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 /> [B'Liquid&solid waste disposal autensii washing sink <br /> (2 or 3 compartments) DSiore frozen food [2-vehicle wash facilities <br /> EB'Preparaflon of food [RHot&cold water for leaning �ilet&hand washing EaStore refrigerated food <br /> LT S�lore dry food/supplies 13Providepotable water L.!]Overs <br /> h7tpa,"ng EyAdequate electrical outlets <br /> Sicinatilre 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 Sofa MFPU APPLICATION <br /> 7/18/2008 <br />