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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): TC!S G R ( L� <br /> Address for Vehicle: Z <� /�,� 7/S S-rcck76A,1 '9'-20 <br /> Street Address city <br /> 1) License Plate* F6 7oZ 9 4) Year: ? 77 <br /> 2) Vehicle Vin #: 5) Make/Model: (f 14 E G`' <br /> 3) State Decal #: 6) Color: �� I <br /> VEHICLE OWNER INFORMATION <br /> Name: �� I AIIi'/ rzz%&� 5 - <br /> Address of Owner: Z _5'T6)(fk Y <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 permit revocation and penalties. <br /> Ac" A-6 <br /> -Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: V&!)At 0 / G 1U 6 L1 C <br /> Owner Name: S fix 1G 77f� b <br /> Site Address: ( <br /> q Street Address city <br /> Phone: ( / ) .�S ( <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 /> Q Liquid&solid waste disposal I�Utensil washing sink Store frozen food DVehicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food Q�lot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> L <br /> ED/s'-toredryfood/supplies [Zrprovide potable water Dbvernight parking Adequate electrical outlets <br /> Si nature 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 /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />