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10/18/2017 09:57 9168758588 PAGE 02/02 <br /> Oct, 18. 2017 9: 15AM No, 2463 P. 2 <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Plaase provide all information requosted. An ihcomplete application may delay approval. <br /> S ����., S r��t� �rr`x ^�`: i:Lki!e" ;K'Yi Rig•? :`iq;e' id`;%,j�{:':�:,,+�,5�k R <br /> Vehicle Name(DBA); A5h'add 011 <br /> Address tar vehicle: 1100 RRoherds Blvd SaCrgrren"I <br /> streac Addroms cny <br /> 1) License Place S: 4NZ149A 4) Year: 2017 <br /> 2) Vehicle Mn 0: CA1163647 �) Make/Model; SPNS VAN{rralier) <br /> 3) State Decal a. N/A 6) Color: Crelam acid Oteeh wrap <br /> ::V�111 • '. I q1. k <br /> Name; Venice Labra <br /> Address of Owner. 33161 a N. Ni htandS <br /> e(mat AaEtea9 qty <br /> Tho mobile load faculty shall operate out of a.rommisaary and shall repon to the commissary ar(east ondeleaoh <br /> Operating day for ofeanmg and servidlng (CalCode suctiorla 11$295 &114297), If the use aUhe.coritmieaayis <br /> dlseantlnuv a permit holder must notify this-ofRne to make the neoeseary changes. Failure to notify 1Ma <br /> Wif exult in penrill revocation and ponaltlen. <br /> 10/10/17 <br /> Si nature of Vehlcle O erator DereN . 1 <br /> Y> f RFF <br /> W,:,. `• :. 1 J.rS,r:a°iiT` kay:';a' Yb <br /> Business Name: r <br /> Owner Name; C, �c <br /> Site Address: <br /> V sweet pdereas Qty <br /> Phone!61(-) <br /> I,tha commissary owner,can and,will prov+da the nocersarq'raolOttus for the above mentlaned-vehicle at my <br /> commissary as chaci(ed below , <br /> Z�Lkiuid 8 solid waafe dls salmi U1Bnsil washing 614 I�,.� <br /> (t ar a oceipenlnenn) .9„ore froten food 2VeMCe'v40-fadl at <br /> �ropafadcn of hood HDI$oWd water fat rlaaning ioilei&hand wash <br /> _ to 931—tore Fefdoaraled lobd <br /> P-<-Io'ra dry foodhiimlicel ide oolable Wa(Dr vemLghl parking goqusla eleelrinal OU590 <br /> s!gnMre of omrnlssa`,( owner/0 eralor . Date <br /> y":�''�"'Y. ,1,ta•,w. ti'17'Y;r•=::�'' ."a'.s : °,.,+,gY�:,.'.�'-rs�. ��' r.+: •� - + <br /> .id n'r.�,i.`yL•V?%h.'e i.`:�tY `r; /',}s.. . u;Lc,^,;. <br /> If the ctlmmlssarylfood estahlishmentle aatsido San Joaquin County,the local health 1WIS fictlhn must verify <br /> aurrent heaftli •t b Igning below. Commissary/food estebllshment Is in <br /> Counly <br /> Si011atwe of County REHS Dato <br /> BiD 18-DI7 MFPUAPLI9A <br /> 711w200e 5 0(0 P 'n0• <br /> Received Time Oct. 18. 2017 9:48AM No- 2467 <br />