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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): D-MEATBARREL <br />Address for Vehicle: 1570 E F STREET OAKDALE 95361 <br /> <br />Street Address City <br />License Plate #: 4NK5262 ' 4) Year: 2014 <br />Vehicle Vin #: 4YMCL1626EN015046 5) Make/Model: CRONT / CARRIER <br />State Decal #: 26079 6) Color: BLACK <br />VEHICLE OWNER INFORMATION <br />Name: DONALD 1 DEGRAFF <br />Address of Owner: 508 DALES PONY CT. OAKDALE 95361 <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 />Dvally vgred cry Donald J DeGraff <br />ON: CN = Donad J. DeGraff C = US <br />Date 2015 06.28 1152.10 -59oo' 06-2945 <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION , <br />Business Name: Z A Co/x2/ 3 a 2-7 /23C)e,.5-/-77 <br />Owner Name: ChC(C/ S ./Cti -) <br />Site Address: on --7 IA ,.. -± /-72cde_57-0 / • (.t 9-5 3 _.5" <br />Street Address City <br />Phone: (705) 33,5 <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 & solid waste disposal j71-Store frozen food 17Kehicle wash facilities .Miquid (2 or 3 compartments) <br />Preparation of food 2-Hot & cold water for cleaning Toilet & hand washing ZiStore refrigerated food <br />Z-Store dry food/supplies j1 Providepotable water 2/Ovemight parking 2 /-dequate electrical outlets <br />./d1612 11P? - 4 7 <br />ignature of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <br />If the commissarylfood establishment is outside San Joaquin County, the local healthlUrisdiction must verify <br />current health permit by signing below. Commissary/food establishment is in -7—,1"1/ 5 Ce-'----ztf <br />County. <br />Signature of Coun y REHS Date <br />EH/0 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008