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Jan 03 18, 04:33p La Comisaria 2093383665 p.2 <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all Information requested. An Incomplete application may delay approval. <br />F <br />VEHICLE INFORMATION <br />Vehicle Name (OBA): E -4/ Mai/MI° al Liras_ gekrti2 <br />Address for Vehicle: 'OW -74h Maaffat <br />sveet Add.. <br />License Plate Pp: <br />Vehicle Vin <br />Stele Decal ft: <br />ii40129A <br />24 itL4WO <br /> <br />Year: <br />Make/Model. <br />Color, <br />PerV5 <br /> <br />VEHICLE OWNER INFORMATION <br />Name: (14v4idri <br />/701* 37(L7Aile Wit cA z1S2-110 Address of Owner: <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 />COMMISSARY INFORMATION <br />Business Name: let (eyniariet ,11091125/0 <br />ArAir,0 Ydf <br />500 7/617 Sfre-e74 di) Street Address City <br />Phone: a.* FAx 6;9) 331 3(94049— <br />I, the commissary owner, can and will provide the necessary facllitleis for the above mentioned -vehicle at my <br />commissary as checked below: <br />Owner Name: <br />Site Address <br />Yriquid & sad waste disposal <br />VIceparation oF food <br />2<lensil washing sink <br />42 Dt 3 comportments) <br />Lij<Ct & rxitei water for cleaning <br />1O-5 tore dry foe tz pliii:S <br /> Plrovide potable water <br />ir:attE -v 1/3e/i? <br />ure of Commissary Owner/Operator Date <br />EA LT alr MOT 'Qf <br />lithe commissary/food establishment Is outside San Joaquin County, the local health jurisdiction must <br />currant ksatth pennit by signing below. Conunisilaryitai* ealtal$10111efitifk -P3 • <br />County. ' • <br />kinalure <br />0*w - <br />MSS - <br />—Received Time —Jan. 3.-2018 — 4:20PM—No. 2813