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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION l <br />Vehicle Name (DBA): SCS ' y TVU t; He Dr; - o ✓� <br />Address for Vehicle: <br />Street Address City <br />1) License Plate #: _ 1 C� X (p 2g 1 4) Year:p �, <br />2) Vehicle Vin #: L L �/) 23 (,� /ak�e/Model: L <br />3) State Decal* 6) Color: Sj G y1I�S� <br />VEHICLE OWNER INFORMATION p r, <br />Name: A Zl Zt Hoincudlo <br />Address of Owner: } W�-e- L <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 />disgontinued, 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 />Si natu?cb#-�fEhf�tc9aasatQr Date-- I <br />COMMISSARY INFORMATION ` <br />Business Name: S( 1 " C(' j'' 1� �f��1' � �< <br />ori s <br />onderful Ice t-,rearn <br />Owner Name:2626 <br />Westlane St #Kt 10[) <br />Site Address: 7 A <br />Sfi <br />(209) 469-2626 <br />5 cJ�cZ,� <br />-- Street Address C4 <br />Phone: (�oq)�i <br />1, 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 dUtensil washing sink <br />Store frozen food❑ Vehicle wash facilities <br />(2 or 3 compartments) <br />❑ Preparation of food Hot & cold water for cleaning Voilet & hand washing Store refrigerated food <br />Store dry food/s lies Provide potable water ,Vovemight parking �dequate electrical outlets <br />Si t e of CommisbaqrOwnerloperator 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 <br />7/18/2008oo6 5 of 6 - - MFPU APPLICATION <br />