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VERE9CATDON VEMCLE CONMSSARY
<br />Please provide ail information requested. An incomplete application may delay approval.
<br />VEMCLE llt\FORifiATIIPM-.
<br />i , Vehicle Name (DBA): el,i6t. 1 „..
<br />Address for Vehicle: .01 9e,W e 4 fziahi ff e;th.e., ,...,&,:ect:b7;,,,,, iti, eic)r -i- - StestAddms 0 / City
<br />License Plate #: q it kiu eAse----- 4) Year:
<br />Vehicle Vin #: LY/L.a .6-3)-7Pel.5.7 5) Make/Model:
<br />State Decal tp: e 4 6) Color:
<br />-V E H IC L E- 0 IN NI ERA M Fp RTEATI 0 Pi --
<br />. Name:
<br />' Address of Ownir: iv' ,,,,,,._44.,.„'.„,
<br />1 Street Address der City /7
<br />. i The mobile food facility shell operate out of a cornmissaty and shell report to the commissary at least once each
<br />oparatino day for cleaning end servicing (Ceiccde sections 1149M A 1147127). if the use of th e 0,,nrimier:v, is II
<br />discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this 1
<br />office may , -sul -7 permit revocation and penalties.
<br />1
<br />(/1 i'D ,
<br />i
<br />Sig.--''7ure of le Operator Date ..
<br />CORRESSARYiNFORMATEON.. -..
<br />Business Name: \____-_,_____ac,,AN,A-___CLoc" poca:kk.rin . _
<br />Owner Name: P
<br />s--1, R . " C \r-N*1 /4 n'' /IV( A2.--i-k‘ ,r-S- r.
<br />Site Address: 2q 00 E. 1-_(--a\-r\G ,k),/),,,,- , 6-koc,,,,con CA cit52o;')-; ' . Steet Address -J I City li i II i Phone: (20A) tek (01A- i..- 5 -}0
<br />f
<br />i I, the
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<br />4 N./ 3 ., 3 —
<br />‘4 commissary
<br />commissary owner, can and will !provide the necessary facilities for the above mentioned
<br />as checked below:
<br />a Utensil washina sink Liquid & solid waste disposal . - (2 or 3 compartments) I Store frozen food .
<br />Preparation of food Hot & cold water for cleaning ' Toilet & hand washing
<br />StorZe dry food/supplies
<br />
<br /> Prov' e potable water E Overnight parking e \
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<br />t , !
<br />I ' ie;
<br />
<br />vehicle at my u
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<br />
<br />Vehicle wash facilities c
<br />
<br />El Store refrigerated food 1
<br />11 El Adequate electrical outlets 1
<br />g
<br />& I Signature of Commissary Owner/Operator . Date 1 l i r ii-illEALTH DEPARTHEEt.7.•'- t - .
<br />i I If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verity
<br />current health permit by signing below. Commissarylfood establishment is in i County.
<br />l
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<br />I Signature of County REHS Date
<br />END 16-017 5 of 6 MFPU APPLICATION
<br />7/1812008
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