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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): <br /> Address for Vehicle's -!- (� ¢{ ` rJ 0 �:> C) Cit <br /> Street Address City <br /> 1) License Plate#: 5 1 4) Year: 1 °� <br /> 2) Vehicle Vin#: �-FC�E 3cl [_S 1ylfit N"CP S qi 7,35) Make/Model: oKD <br /> 3) State Decal#: 6) Color: U' <br /> VEHICLE OWNER INFORMATION: <br /> Name: �'e-fv Z ZCAi'I'l6 <br /> Address of Owner: �q,Z C I _ 0 -40 -b 4 / (p g30SV S / <br /> Stree Address city <br /> outof.. J _L 11 ..o"to the .. 3� ,- 1=^^a <br /> iilC IiiV CiiiC IVvu iGi.:iiLy 3iiGi: Ci�.ivi GCC ViiC'v: G a7iii :iaii is I.i VIC LV CIIC C.'v ilii::^ .^-..i s"GC ...G <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 /> 1c, 2c f�I <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: oC4,v-on'S 1�D�1� ' -�—C_ Ct%OUit/v <br /> r Owner Name: <br /> Site Address: <br /> Street Address city <br /> Phone�oO) � C '�I�p — Z&2 <br /> I, the commissary owner, can and wilj/p(rovide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: / <br /> ❑ Liquid&solid waste disposal Utensil washing sink Star,frozen food V ficle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food ❑ Hot&cold water for cleaning Toitet&hand washing ✓ tore refrigerated food <br /> ❑ Store dry food/supplies ❑ Provide potable water overnight parking Adequate electrical outlets <br /> Signature of Commissary Owner/Operator Date i <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 5 of 6 MFPU APPLICATION <br /> 7/18/2oo8 <br />