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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): (7 er 57—e:, _5' f--;. es r — --,1. <br />Address for Vehicle: /3 v? F TE-,z,- ri er7 gd -c. .•/,`. <br />Street Address City <br />1) License Plate #: g 1241 F4/1 4) Year: <br />9) Vehicle Vin #: /F-66 Fr5/(y 2 EcAO yg5- 5) Make/Model: <br />3) State Decal #: d:ri 1 0 ( Rot3 5) 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: PO ();(‘ c_c57--?,-, <br />Address of Owner: 999 rearc....i.,ro ( , k <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 r in perm revocation and penalties. <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: _c,s-,--e-,_ _:c-• /:-_-_, ,_1 esr jr,e7.7 4/.. <br />Owner Name: / `n r., 57--,i <br />, o Site Address: f3, F 17...tr yleg. kai A cf,--- -• ii <br />Street Address City <br />Phone: (20 ) c?'/0 -6G6g <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 />sink h il washing sn Liquid & solid waste disposal tens Store frozen food ,F1 Vehicle wash facilities (2 or 3 compartments) <br />RPreparation of food 11 Hot & cold water for cleaning Toilet & hand washing Store refrigerated food <br />Ft Store dry food/supplies .1[ Provide potable water tOvernight parking ,F[ Adequate electrical outlets <br />/0 --N-4 <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 />11/j i ° <br />Si taturz . Count EHS Date' <br />EHD 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008