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VERIFICATION OF VEFIrCLE COMMISSARY <br />Please pr-avide-aHiriformatiort-r-equestedF rt_incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): .1/ ( k i 'S <br /> 1Ec A rE FR / <br />Address for Vehicle: 97() 5t z4R1 liv e s-Tei cK 7-C /; c' 9,_5---,z 0 ,_,,---- <br />Street Address City <br />, <br />/_, <br />License plate #: t ff ttv • t t --) — 4) Year: (2 o /3 . <br />Vehicle Yin #: 5) Make/Model: <br />K.)) ,...•Ult11 . 5ILUE1- State Decal #: ,,,. e•-•.-.1.-..,• <br />VEHICLE OWNER INFORMATION <br />Name: ///,/ C7 i 1_1 ilil'A/4 <br />Address of Owner: ? 9 6 _5raiee/ ri4/6- 5 7 --0 k-To A/ c. ii! ?52 i 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 />i ...' -- <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: 6? (‘,1 / 6.)/i) CL/I:/6---W/ Al 6 'OW C <br />Owner Name: S:fi?..._ Uf-1-0g_ .178. 4,0 a <br />--zit. Aririrpqq: (7 (7 .‹ f,( ft /1 t 41 ST _..-,7Z)--K-rok, Cit <br />Street Address City <br />v Phone: ( ) (2 t155 -- :5-4-/ / <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 />,- E-btensil vvashing sink Liquid & solid waste disposal D4tore frozen food Vehicle wash facilities <br />(2 or 3 compartments) <br />DP/reparation of food 1-1/Hot & cold water for cleaning E Toilet & hand washing 19/Store refrigerated food <br />ore dry food/supplies II Provide pot water E Overnight parking [9/Adequate electrical outlets <br />, _ t <br />Signature of Commissary Owner/Operator Date <br />.HEALTH DEPARTMENT <br />lf the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />establishment is in current health permit by signing below. Commissary/food <br />County. <br />Signature of County REHS Date <br />EHD 16-017 <br /> 5 of 6 <br /> MFPU APPLICATION <br />7/18/2008