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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): 0N6 1-01 Al 4 -rptig <br />Address for Vehicle: 49)00 f LOW) PO Mt (LO P,1 Ur <br />Street Address City <br />License Plate #: 4 I) 1 ';3-7(1 4) Year: 202 2 <br />Vehicle Vin #: 5) Make/Model: 1VI VIT-- <br />State Decal #: 6) Color: lAilitie <br />VEHICLE OWNER INFORMATION <br />Name:10 PiLe, NCe NA A6 1-1'' <br />Address of Owner: 54'2-1 az-t-Lerr L, v „tidowtter-, 6.-A-. q.5815 <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 pera1f revocation and penalties. <br />-----C—-7-- __...--1..„-, 3 i 25 <br />Signature of Vehicle Operator Date <br />COLUAISSARY INFORMATION <br />Business Name: Z:AL.f i 0 (- \J,4 G Dii,1 ,,VIISS-i12-k-1 <br />Owner Name: (2-INU L 11 <br />Site Address: 458 00 f li.,-,3 n A.) 0-4) ,<Jia..om5i1tro <br />Street Address City <br />Phone: (o11() 2-0 - 1 52- I <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 />N \ Utensil washing sink , Liquid & solid waste disposal n Store frozen food fq Vehicle wash facilities (2 or 3 compartments) <br />.1\ \ Preparation of food \ Hot & cold water for cleaning \ Toilet & hand washing I Store refrigerated food <br />\ Store dry food/supplies \ Provide potable water Overnight parking M 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 />S 5-- <br />Signature of-County REHS Date <br />END 16-017 5 of 6 <br />MFPU APPLICATION <br />7/18/2008 <br />Pg2_ (V31-0