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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): Mhm3 /r Y//Y N 5-r4p e fT 341Z11 <br />Address for Vehicle: • ©d5-" 5(AR 0Av JqNi,� Sfoc-k'Tnp/ to S2/b <br />Street Address City <br />1) License Plate#: IF00111(49 CA 4) Year: 1991 <br />2) Vehicle Vin#: IQC"e3,�o° Make/Model: VL%!Y VA/1 <br />3) State Decal* 6) Color: WH/if <br />VEHICLE OWNER INFORMATION <br />Name: IIANj/i .f'/' Cil <br />Address of Owner: 706.5- SH#gPp'c►I✓ 41qAes Tom/ ' C.FFQON-0 <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: plawo_ ao l CE eZxA1✓i',5 <br />Owner Name: S l"W <br />Site Address: t,1 0141ER pTp/I/ eA 15,Va5' <br />Street Address city <br />Phone: (J'%) <br />1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />❑ Liquid & solid waste disposal ❑ Utensil washing sink <br />(2 or 3 compartments) [Store frozen food Q Vehicle wash facilities <br />❑ Preparation of food RrHot & cold water for cleaning Toilet & hand washing ❑ Store refrigerated food <br />❑ Store dry food/supplies ❑ Provide potable water Overnight parking Adequate electrical outlets <br />Signature of Commissary Owner/Operator 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 />EHO 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008 <br />