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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): 2 � ' <br /> L G- C,, i�S h 0Tl f/% / h& <br /> Address for Vehicle: 2 C!C C7— Is s. T %5 5 <br /> Street Address City <br /> 1) License Plate#: '-/ 35 `%(Z / 4) Year: /95r <br /> 2) Vehicle Vin #: jG(./W92-1 ; 7i= :51aZ2 7 5) Make/Model: Ct7�V /c�..i <br /> 3) State Decal #: 6) Color: L/ /'K k.;rT ` F1-41; � <br /> VEHICLE OWNER INFORMATION <br /> Name: e,.- c.5 <br /> Address of Owner: J " d <br /> l N,dLiss C iSCGrck <br /> SAddrecity <br /> treet <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 /> offic ay result in p9rmit rev ation and penalties. <br /> Signature of Vehicle Qgferator Date <br /> COMMISSARY INFORMATION <br /> Business Name: C6,1 C`_e4 <br /> Owner Name: SQL e;Ji;< f' <br /> Site Address: 1717 j T- <br /> 2(->qZC> Street Address city <br /> Phone: ( �( �/. q <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 tonsil washing sink <br /> (2 Cr 3 Compartments( tore frozen food Q•/vehicle wash facilities <br /> ' <br /> Preparation of food Hot&cold water for cleaning Q Toilet&hand washing Store refrigerated food <br /> Store d food/supplies Provide potable water 3/overnight parking Adequate electrical outlets <br /> SI n ture of Commissa 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 /> EHO 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />