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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> 4VI6HICLEINF0RMATI0N',. - -, <br /> Vehicle Name (DBA): L S C AMCR104 aw W3 CE FR/ t1G <br /> Address for Vehicle: - i p ( f p��f p GJ .5�0 <br /> Street Address City <br /> ,1) License Plate#: G 7 5;� 4) Year: o9612- <br /> 2) <br /> 20/ Z2) Vehicle Vin #: 5) Make/Model: kakyglAlEg <br /> 3) State Decal #: 6) Color: C <br /> 'VEHICLE OW/NER INF._ORMATION <br /> Name: R06 - - <br /> Address of Owner: /7.2 q S, E /f(/C S' 6 O S <br /> Street Ad ress city <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> operp for cleaning and s alCode sections 114295 & 114297). If the use of the commissary is <br /> dis the ermit hol must notify is office to make the necessary changes. Failure to notify this <br /> o IcIn pe it r cation and pen ties. <br /> 5 ature of Vehicle erator Date <br /> '�COMMI.S.SARY INFORMATION <br /> Business Name: UIV p CA C CErtlTci� <br /> Owner Name:1S <br /> Site Address: 17Z7 S, ottl s O c �<T6CGf -6-.2, O c <br /> —26 V 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 /> Liquid&solid waste disposal' alltensil washing sink ore frozen food VehiGe wash facilities <br /> �(2 or 7 compartmental <br /> 0preparation of food u Hot&cold water for cleaning oilet&hand washingSt re refrigerated food <br /> U$tere-dry food/supplies Provide potable water Ovemi ht park' g Adequate electrical outlets <br /> 1 D D / <br /> Sim of Commiss Owner/O erator Date_ <br /> IHEAL-TH DEPARTMENT y T <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 /> 7/18/2008 <br />