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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION _ , ----) ' Vehicle Name (DBA): 1-L.;:T <br />, <br /> 17-E <br />Address for Vehicle: <br />Street Address City <br />License Plate #: j 9 -.4 5g DZ. 4) Year: <br />Vehicle Vin #: ;),; pz 1, p 7423355 0-o5 5) Make/Model: <br />State Decal #: 6) Color: Z.,/6,41- e..:,,bi, 6-11-.za j-,,.' <br />VEHICLE OWNER INFORMATION <br />Name: 5 ,,,...N; .-.7_,...Dcriz. .1---z:c.:7D / .\/<\ <br />Address c, of Owner: 32_, 5 v O N, q 5 5 6 ey 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 office may result in permit revocation a alties. <br />..-^ . <br />T7-4;5/11' <br />STriature of Vehicle Operator , Date <br />COMMISSARY INFORMATION <br />Business Name: EiR c3,06611a N oetto 710 <br />Owner Name: ie a 000061-,^ 44iv <br />Site Address: 500 7 <br />'Y't ' 40 k, 10 filoeem i0,0, (1535 q Street Address City <br />Phone: (cm 33,---3(a 6,3 <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 />Utensil washing sink %-Eiguid & solid waste disposal 7 Store frozen food g_ Vehicle wash facilities (2 or 3 compartrnents) <br />IVI Preparation of food FI- Hot & cold water for cleaning U Toilet & hand washing I I Store refrigerated food <br />g_Store thy food/supplies l_Provide potable water MOvernight parking R] Adequate electrical outlets <br />4/(/,:d <br />Si ture of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local heth Jurisdiction must verify <br />current health permit,by signing below. Commissary/food establishment is in -- rUtili. (au r County. <br />1 /5 <br />Sig e of Co ty RENS Date <br />EHD 16-017 <br />7 /18/2008 5 Di' 6 MFPU APPLICATION