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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): k--- i m oo 'pia arms k p en 0., <br />Address for Vehicle: ke- V 1411 sty.a4-- 5,04 D MaitS10/ CA 00W I/ <br />Street Address City <br />License Plate #: qv.) 9092 4) Year: <br />Vehicle Vin #: L1.4 1192(j0 5) Make/Model: SPCA/S <br />State Decal #: 6) Color: Orangei <br />VEHICLE OWNER INFORMATION <br />Name: Aid ralvdri D <br />Address of Owner: 1701/1/ 704 riwe fd tarh1 (A qszijo <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: La_ Cowlcanit ,Und.e51t) <br />Owner Name: A-Mi) WM./ A. <br />Site Address: 5100 AM SI 7 eel- Qll .1.) pa isle CA .*-35 <br />Street Address City <br />Phone: -Gq) ,4- 5&10,.3 1;i)e. bi -vg) <br />I, the the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />sink TM/Liquid & solid waste disposal vt<tensil washing K.Store frozen food 4---i'Vehicle wash facilities <br />(2 or 3 compartments) <br /> 'preparation of food rP4t & cold water for cleaning [P't/Oilet & hand washing 4-"'Store refrigerated food <br />VStore dry foo , supplies . IVProvide potable water rfr<ernight parking It4dequate electrical outlets <br />fr/t' <br />ig ure of Commissary Owner/Operator Date <br />EALTH 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 />EHD 16-017 <br /> 5 of 6 <br /> MFPU APPLICATION <br />7/18/2008