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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />1 — Vehicle Name (DBA): v i ,c_ K, tri, ._5- H UT 49 0 6 ?-. 2 <br />Address for Vehicle: 3 q ( 1 /1/ i 4 1?-1 ,9 pe srodre., ni fil 95i <br />Street Address City <br />License Plate #: z/.0 iv 6, c, 3L 4) Year: 2 C/ 2--- <br />Vehicle Vin #: 5) Make/Model: fi REE M <br />State Decal #: 6) Color: R 13 <br />VEHICLE OWNER INFORMATION <br />Name: <br /> <br />Address of Owner: 3i, / 1/ /L7 5 R r ge6---57,--c (KT -n/12, ,- h.' .±}.2 0 <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 />rikili 'T‘' 6 y 14 <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: 00 O 10 (.7__If 7-6 - - R i W6 -Tx u c k cErurck <br />Owner Name: Sieli vgok -Taw a <br />Site Address: /7 / 7 s_ ((J/0 4.--/-i- 5-To c k ye) Ai c /( 9512_ O 6 )- <br />2 (f ?Street Address City <br />Phone: ( ) <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 />ZI 7 /Utensil washingsink Liquid & solid waste disposal 27Store frozen food Vehicle wash facilities (2 or 3 compartments) <br />rq-Preparation of food Wlot & cold water for cleaning Ejfoiiet & hand washing I—Citore refrigerated food <br />MI-tore dry food/supplies 7/Provide potable water Er(:)vernight parking 111 Adequate electrical outlets <br />/ <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 />Signature of County REHS Date <br />EHD 16-017 <br /> <br />5 of 6 <br />MFPU APPLICATION <br />7/18/2008