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<br />VERIFICATION OF VEHICLE COMMISSARY
<br />Please provide all information requested. An incomplete application may delay approval_
<br />rintitel: m" 5 s',;, 0 2'ke 's *1. - , :f1,1107L, 224frarafk,, ,),,...ett. .J.. .mg-trilaMt
<br />Vehicle Name (DBA): --"\lisz_____ U. -*\ - - - S itA-5 -
<br />Address for Vehicle: "- \ 1- Cc-sr\ Gsfel (-1- , Uo
<br />Street Addless City
<br />Li V P C-.3 6 ,?, 1 L• i )-0 License Plate #: % • 4) Year: ,
<br />Vehicle yin #: (7 1_2,2-5 •)---‘ 1-•/ ° 5) Make/Model: 44 to 1) E
<br />State Decal #: C A cto \\ 6) Color:
<br />4-vejr,7Tirr - J ,,,,,,f4r:-.:,,,,,r,,,--140 , ,,,,,, .71 Ise • 1 e -341ftair , ' 7: -; ,,: , . .,, ,.., , . .. _ ,, .. e , : a NO
<br />...K
<br />Name: Af t i' Jr
<br />Address of Owner 3 \. q- - t___,L,-- &t_ 9. sa tites v
<br />Street Address City
<br />The mobile food facility shall operate out of a commissary and shall report to the commissary
<br />operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use
<br />discontinued, the . - it holder must notify this office to make the necessary changes.
<br />office may :-. 0 t,- rmit revocation and penalties_
<br />\ -
<br />at least once each
<br />of the commissary is
<br />Failure to notify this
<br />Signature of Vehicle Operator Date
<br />1414,44704@r-Nitira*r‘" iPLO,r7,-17/01-Etitr!"'f". :_Miterige21477: -ih-4--?'
<br />_.
<br />Business Name: Co rr\ y\r\ k S s, ,v A ----ire cc,
<br />Owner Name: p,ke_ jek-v,:.Jvp 06A0 q . 6D- 0 _ _S .,ii-eir -b-sne r),--\-0, Si- , i__,.. cjii:c-L, ,
<br />_ Site Address: 6, 2_€, . 5 , sa_ e_v- ,g c, -1,' ,,e_,4.1.3 ' s_N 1: .-A- , , (`'E 9 c. 11 C7'
<br />
<br />Street Address City
<br />Phone: „2-4-1 la tA, a-3 5
<br />I, the
<br />commissary
<br />Ffrfiquid
<br />12‘eparation
<br />commissary owner, can and will provide the necessary
<br />as checked below:
<br />& solid waste cfisposal I Utensil washing sink
<br />tz or compartments)
<br />of food Hot & cold water for cIeaning
<br />re dry fooditsupplies rq‘vide potable water
<br />a (1 4)---- 1
<br />facilities for the above mentioned
<br />0 Store frozen food
<br />ri Toilet & hand washing _
<br />Overnight parking
<br />i ?..__ 2. _
<br />vehicle at my
<br /> Vehicle wash facilities
<br />I i Store 'LSI igerated food
<br />Adaquato oltdrical outlets
<br />Signature of Commissary OwnerlOperator Date
<br />,
<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 RENS Date
<br />EHO 16-017 of S MU APPI_1CA1ION
<br />7118/2008
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