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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): \ I c,yc( /TZ-k, <br />Address for Vehicle: //0/ 5, <br />Street Address City <br />License Plate #: HO v\1 1-.35 4) Year: 200 Li <br />Vehicle Vin #: i [1,B E al 1 GI-M001 li 5) Make/Model: F &TR L Afi; Ii4y <br />State Decal #: /7n3 6) Color: V\41:1-(_ <br />VEHICLE OWNER INFORMATION <br />Name: // eclor k , ijiiis <br />Address of Owner: 1kt ROI kfunwoor\ w o y <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 />"ZXA7 -C --__ ' / /..; <br />'Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: ' <br />Owner Name: 60h „64 7 $ 11/1-4 <br />Site Address: / g/ S, _C' C/GACAt f d a 9'.'vb _...., ) <br />Street Address City <br />Phone:( ) 3 L/ S73 <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 El Liquid & solid waste disposal washingsink Store frozen food ErVehicle wash facilities <br />(2 or 3 compartments) <br />Lii <br /> <br />Preparation of food ErHot & cold water for cleaning Toilet & hand washing Store refrigerated food <br />Store dry food/supplies M Provide potable water IY)vernight parking DAdequate electrical outlets <br />Signature of Commissary OwnedOrtator Date <br />HEALTH DEPARTMENT / <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />health by signing below. Commissary/food establishment is in current permit <br />County. <br />Signature of County RENS Date <br />END 16-017 <br /> 5 of 6 <br /> MFPU APPLICATION <br />7/18/2008