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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): ON6 - kkM AT 4, fVkll17 <br /> Address for Vehicle:4s(j() F Lou <br /> Street Address city <br /> 1) License Plate#: 4 4) Year ?-rxz 2 <br /> 2) Vehicle Vin#: 5) Make/Model: MM T <br /> 3) State Decal* 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name:A 0 KG NCC— M A6/K <br /> Address of Owner 154 rt D -P t-LG—T-r 1,V <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 pe revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 11-oA jj;A. <br /> Owner Name: IC—Av '( <br /> Site Address: +8 0 U �'f AJ "D <br /> Street Address city <br /> Phone: (��� ) 2�'0 '- 15 2- 1 <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 /> QLiquid&solid waste disposal 0 Utensil wad)k FA Stone frozen food EJ Vehicle wash facilities <br /> Q Preparation of food Q Hot&cold water for cleaning Q Toilet&hand washing Store refrigerated food <br /> ©Store dry food/supplies Provide potable water Overnight parking Adequate electrical outlets <br /> 3/Z 5 <br /> Signature of Commissary Owner/Operator Date <br /> HEALTH OEPAR'fMENT <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 /> S , CeN <br /> Signature orCounty REHS Date <br /> EHD 1"17 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />