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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): cute) OW& pc,(S !O—E C R E11M <br /> Address for Vehicle: s'ronkz of c1i ZaS <br /> Street Address City <br /> 1) License Plate#: 0� " �( 1 4) Year: C'901 S <br /> I <br /> 2) Vehicle Vin #: 31%1,6"C/Y7 0k4V8T— <br /> k72 375) Make/Model: <br /> 3) State Decal #: C4 �3L4) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: YSiLVl�q -78.00 ' H C 44-1 <br /> Address of Owner: dl S'C c S/ - C,�Tn/�� C4 <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 /> offic 'M)y resultmit revocation and penalties. <br /> A 1� 9/ <br /> Signatur of Veh le erator Date <br /> COMMISSARY INFORMATION <br /> Business Name: St C <br /> Owner Name: <br /> 2626 Westlane St#K1100 ream <br /> oma 95205 <br /> Site Address: (209)469-2626 <br /> 'treet Addres 9-2073 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 ❑"Utensil washing sink <br /> (2 or 3 compartments) Store frozen food Vehicle wash facilities <br /> ❑ Preparation of food ❑ Hot&cold water for cleaning Toilet&hand washing Z Store refrigerated food <br /> ❑ Store dry food/sup Pr vide potable water Overnight parking [Adequate electrical outlets <br /> Signature 6f Commi 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 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />