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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Q-1:L f I NF0 <br /> RKIIA 10N <br /> Vehicle Name (DBA): so C <br /> Address for Vehicle: - S(�f(k /?Pd?tj (1,16 ?s2qo <br /> Street Address city <br /> 1) License Plate#: 4) Year: � 0((o <br /> d� <br /> 2) Vehicle Vin 7 <br /> 5WKU90a3 1 037 (o Make/Model:— <br /> 3) State Decal 6) Color: <br /> " <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> y[YAZ— <br /> Address of Owner: [OnA La Ke Wr-K PA # 'IS() <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 result in permit revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> M- M' ISSARY, INFORMATION , <br /> Business Name: &7±�Z, <br /> Owner Name: ' <br /> Site Address: 24- !152SL6 L 6DI <br /> '566 <br /> Street Address city <br /> Phone: (70e) ) 7J_2 (Q�; 5-7 <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 /> M/Liquid&solid waste disposal E] Utensil washing sink F-1 Store frozen food El Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food ®�&cold water for cleaning ❑Toilet&hand washing ❑ Store refrigerated food <br /> ,Ktore dry food/supplies ❑ Provide potable water �verniqht parking ❑Adequate electrical outlets <br /> Signature of Commissary Owner/Operator Date <br /> HEAf <br /> LT DEPARTMENTrV. <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 /> END 16-017 5 OF6 MFPU APPLICATION <br /> 7/18/2008 <br />