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VERIFICATION OF VEHICLE COMMISSARY
<br />Please provide all information requested. An incomplete application may delay approval.
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<br />Vehicle Name (DBA): M ovi..,z1-, p r , .0. ta,. to Nig Lf1VI
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<br />Address for Vehicle: (- JO( EU k_9reert wood cDk- c-- 1-40M1-0 \ik- CA (q5q0 5 Street Address City
<br />License Plate #: 6/ r; Q 9:(511 4) Year: 1 tqP 7
<br />Vehicle Vin #: 1 ri 13 11 P 3,QYXv,t3i9-1ke Make/Model: Cki EVY V 1 State Decal #: c.ali VO rhi, 6) Color:
<br />, ...,. - Varat ral4M011 ; `; -,.4„ 'i' .; v ti, li,„-,,,, , 5' • . _ -'a .-*-- Name: \,c_osil 0 6.200„-i>me,2
<br />Address of Owner: LU (0 G re p oworkic,\_ c--,tor.x-A-OVI ca g_P5 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 office may result in permit revocation and penalties.
<br />0/i0 %)oicl Signature of Vehicle Operator Date
<br />COMMISSARY INFORM TION , ..it '‘: iii, '`.•,..,,-;::tIa --;.,4 - „. ' , ,i. -T-' ,‘ . ,,11113g,-,A4Ae,•-p ,.. ',. A, o 4, -; L'.. A 7 ., . Business Name: •-4,/./.17 4. d .&'' Owner Name:
<br />Site Address:
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<br />;.)7-- 6,,, L--/le 9J1 treet Address city Phone: (,2d 4) i-)....(73
<br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below:
<br />Liquid & solid waste disposal I Utens 7 I il washing sink L
<br />(2 or 3 compartments) ri Store frozen food [Ye Vehicle wash facilities
<br />I I Preparation of food y-Hot & cold water for cleaning K-41 Toilet & hand washing n Store refrigerated food
<br />I I Store dry food/supplies JProvide potable water Ng Overnight parking VAdequate electrical outlets
<br />Signature of Commissary 0 • 4 perator Date
<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 County.
<br />Signature of County RE HS Date
<br />EHD 16-017
<br />7/18/2008
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<br />MFPU APPLICATION
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