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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): 87-6)Ci T/ 1 L . ',/,--/ ro E,,,71-7 /-ii-- /a ,Zi C......Qgoffil <br />Address for Vehicle: cR,6:2 -• N . tni --.Q.- .Z..77/A-/E A. fe70 STZIC,k 7r) A/ 93;26 <br /> <br />Street Address City <br />, / 6 n , <br />License Plate #: 3 7 i li 8 g 4) Year: /?qg <br />i 41 I C Vehicle Vin #: 11./03 (.21 5) Make/Model: Fc:A.:L <br />State Decal #: 6) Color: 'VEILCC4,7 <br />VEHICLE OWNER INFORMATION <br />Name: Polkit>//1-0E C,i4-rti//79tC 6-- , 6'itik e- 'Isi-b C #el-trivi i‘`' <br />Owner: ?-5 P-)Ri t S7z6-71)Al S=2 Q Address of 3„Q_ 117 4.- 0 /2./v...<1 <br />Street Address City <br />The mobile food facility shall operate out of a con--'-sary 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 /> <br />discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br />office ma(y-rpsult in permit revocation and penalties. <br />--e"- C)t,01-1_,_.---- Cge_c2&kr <br />---)Z- Signature of Vehicle Operator I.5W- C0 -- 4.0/6 <br />COMMISSARY INFORMATION <br />/..5 Business Name: 6770C.k7zw t4..)0 NOE. A Fed__ / c.E_ie..c-----,1 "0 <br />Ps <br />Owner Name: ye:7/Mmify2)E 9"i v. C <br />Site Address: cpc;(/60?6: A-I, tv EST- 6,414E c---A- ci C.), , <br />. Street Address <br />Phone: ()-c'h 1--1 cj - 2 cj4 2-el 1.d9 <br />, j__6 7.„.. City <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 />/ ri Utensil washing sink <br /> <br />E Liquid & solid waste disposal agore frozen food Vehicle wash facilities <br />(2 or 3 compartments) <br />,--#. <br />PreparatiOnStinktOngs WoWcii19816,gctsygpahyr cleaning Toilet & hand washing Store refrigerated food <br />2626 Westl4ne St #K1100 <br />re dry food/ upcSit= On, COliOtria,95210Sable water 11.--Cernight parking 111-12ctiaCTuate electrical outlets <br />(209) 469-2626 <br />-A209) 469-2073 5 17‘ '''f- 6 /6 v711'1-(1Y-/ . rfratia <br />Signature of Commissary Owner/Operator Date cD 3 - A ..ee,16 <br />HEALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />by signing below. Commissary/food establishment is in current health permit <br />County. <br />Signature of County REHS Date <br />EHD 16-017 <br /> 5 of 6 <br /> MFPU APPLICATION <br />7/18/2008