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nate <br />memomminpi <br />POSL Q(Qt <br />Please provide all information requested. An inco,nplete Application may delay approval <br />VERIFICATION OF VEHICLE COMMISSARY <br />VEHICLE iNFORMATION <br />Vehicle Name (DBA): <br />Address for Vehicle: 'bC <br />Street Addrose' City <br />2- c"). 2- 3 <br />TiL <br />License Plate tP _Li ic22-1(c C 4) Year <br />Vehicle Vin faCL A 2 '72.3pq2.9 5) Make/Model; <br />State Decal #: 6) Color: <br />EHICLE OWNER INFORNI-ATTO—N— " <br />Name El3a J C cC1 <br />Address of Owner i.06'.2-Li ct <br />Street Address <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) It 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 potrmit revocation and penalties. <br />1\0'6X-1.0‘ <br />Signature of Vehicle perator <br />_CONIMI§ARY iNFORIVIATIO1•4_ <br />Business Name: <br />Add re s s <br />Phone ( ;-eq) JJV T2L <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 />[Ti Utensil washing sink <br />(2 or 3 compartment:) <br /> Store frozen food <br />t & cold water for cleaning toilet & hand washing ore refrigerated food <br />>tProinde potable wuter <br /> Overnight parking <br /> 0 Adequate electrical outlets <br />nature Commissar/ ., lQ.erator Date <br />ALTO, EPARTME <br />If the commissary/food establishment is outside San Joaquin County, the local health iurisdiction must verity <br />c urrent health permit by signing below, Commissary/food establishment is in <br />County. <br />„ <br />_2/ <br />Date <br />, <br />Oivr. _ <br />Owner Name: <br />Site Address: <br />Liquid & solid waste disposal <br />Preparation of food <br />Store dry food/supplies <br />ehicle wash facilities <br />MFPLJAPF,LiCATION Er-018.017 <br />7/18/2008