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o VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): ecG t I�Dy-r7 t h7 V' D <br /> Address for Vehicle: V,;36 <br /> Street Address City <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: P/ �! — - <br /> Address of 0 er: C/a3 ✓ C ��'�� �` `-/5'30 <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 /> of�fi/de may result in permit revocation and penalties. <br /> Si nattYre of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 0( t U e41-0 -�5 4 n,,,? <br /> CO/I'J777 i 4 v <br /> Owner Name: —Iorq L, Ohu-qwon, e <br /> Site Address: t -4 D 9jsD <br /> Street Address City <br /> Phone: ('lam 6, <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 /> 0 Liquid&solid waste disposal Q Utensil washing sink <br /> (2 or 3 compartments) ❑Store frozen food Q Vehicle wash facilities <br /> ❑ Preparation of food E]Hot&cold water for cleaning EJ—Toilet&hand washing Q Store refrigerated food <br /> Q Store dry food/supplies Q Provide potable water ElOvernight parking Q Adequate electrical outlets <br /> Si nature of Commissary Owner/O erator�/�ra./`�,,,75 Na _ t <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 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />