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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): ONE; -01 AT A fAcql, <br /> Address for Vehicle: U`J F Lorik' r4) DMA W <br /> Street Address city <br /> 1) License Plate#: 4) Year Z22 <br /> 2) Vehicle Vin#: 5) Make/Model: M�TR- <br /> 3) State Decal #: 6) Color: ANHHE _ <br /> VEHICLE OWNER INFORMATION - - <br /> Name:i,�KC- NGC— <br /> Address of Owner: l5rt M'V-tL6T_-r L 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 O erator Date <br /> COMMISSARY INFORMATION <br /> Business Name: LIL f Fo PLN - CDMMISS-o" <br /> Owner Name: ' _AV L, ti . d <br /> Site Address: +8 0 O LO ff AJ P � M151M <br /> Street address city <br /> Phone. (�l !52 + <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 ❑Store frozen food ❑ Vehicle wash faciiiiies <br /> (2 a 3 con4-bn—ts) <br /> 0 Preparation of food ❑Hot&cold water for cleaning 0 Toilet$ hand washing ❑ Store refrigerated food <br /> 0 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 /> 5 , L��s 1/75 � zs <br /> Signature oftounty REHS Date <br /> EHD I"17 5 oI 6 MFPU APPLICATION <br /> 7/18/2008 <br />