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VERIFICATION OF VEHIC_E COMMISSARY <br />Please provide all information re q uested. An incomplete application may delay approval. <br />VEHICLE INFORMATION . <br />Vehicle Name (DBA): g / nf,o,,, (ix4 iA ci ; fil) I ? ' / di ilLO, <br />Address for Vehicle: 7 ,...2 I 6) 4 _, 1,r( et e0z .(Lodi,: eA qTea a 9 <br />Street Address ' J i City <br />License Plate #: . L / K V i p7,2,D 4) Year: 001 0 <br />Vehicle Vin #: 5) Make/Model: 5P CA 0-7- I (V <br />State Decal #: 6) Color: <br />VEHICLE OWNER INFORMAT ON ‘' <br />, / Name: 7 x i (TA (0).1,6 -0 <br />Address of Owner: "7 3 ! a_.„) 4-1 .at 0 NI_ ki3ek: fiA <br />Street Address j 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 ay ( r 2.11ti,,p-er ' revocation and penalties. <br />/ - , <br />na-it- <br />gig atufe of VeVcle Operator Date/ <br />COMMISSARY INFORMATION <br />: Business Name: J- dOifitin ',Sa rex 4 Ma.W1-0 , <br />Owner Name: / 11/71..) 142,zi,,\, <br />Site Address: .1.)0 --7 --111 ,..) a <br /> <br />, . n1_0(114-10. eq-- q .S75 5 L-/ . <br />Street Address City <br />Phone: (62a7) 338---3&40, 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 />sink Fl Liquid & solid waste disposal Li Utensil washing 7 Store frozen food [g Vehicle wash facilities <br />(2 or 3 compartments) <br /> Preparation of food .N1 Hot & cold water for cleaning 41 Toilet & hand washing n Store refrigerated food <br />Store food/supplies gyrovide potable water 13.Overnight parking N Adequate electrical outlets <br />‘ , <br />#7,L &det-04" t- <br />Signature of Commissary Owner/ perator Date <br />HEALTH DEPARTMENT <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 />El-ID 16-017 5 of 6 <br /> MFPU APPLICATION <br />7/18/2008