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VERIFIATION OF VEHICLE CSIMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION ) <br />Vehicle Name (DBA):5 FC:6CIA,,y1 n <br />Address for Vehicle: ; ) 0 /k) vv t is <br />Street Address City <br />License Plate #: (i i --5VC —2-- 4) Year: <br />4=2 v 91/6 Vehicle Vin #: J-C—E, H-1-,3z 2.„5) Make/Model: <br />State Decal #: I% C? 9 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: V-- -t— A Tik fr <br />Address of Owner: Ldt--i; CtLev dt7i-s- (---)-- S'YLa- t7),-) cA g's--- 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 • t notify this office to make the necessary changes. Failure to notify this <br />office m r ult in I :rmit revoca io and penalties. <br />., <br />---7. 2111 7 — jIl Signat Vitr.f Vehicle operator \...1:21..!te <br />COMMISSARY INFORMATION <br />Business Name: _--1-06._)(-0,-) o ' b. A t ,- it( At C-- <br />Owner Name: ic'en il e-71,-N —5-4-re <br />Site Address: .3.556 xi ‘,62/ z: 50.0 i 11 ( <br /> <br />Street Address Z.,,41 "me City <br />Phone: ,e09 ) 6-70 i 11 tj- Z 2 1 --: 4/65• <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 />__.-- <br />7/Liquid & solid waste disposal ErUtensil washing sink r .--S-t-ore frozen food pi- Vehicle wash facilities (2 or 3 compartments) <br /> Preparation of food FTHot & cold water for cleaning [. <let & hand washing Store refrigerated food <br />--- <br />Store dry food/supplies FrProyide potable water ROvernight p.rking R---A-dequate electrical outlets <br />, <br />(-7 <br />.,, <br />Signature of Commissary Owner/Operator late <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 REFIS Date <br />END 16-017 5 of 6 MFPU APPLICATION 7/18/2008