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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION ,.,: F r` s•. <br /> Vehicle Name (DBA): 1S JT;WkEkf APUN Ek ` -4',2,- <br /> Address for Vehicle: iff <br /> GO b VC-050- T6� TD nJ 9 <br /> S "et Address city <br /> 1) License Plate#: 414 E f Ige lS 4) Year: ,20 1 g <br /> 2) Vehicle Vin At: 5) Make/Model: Mfii 1 UT7L <br /> 3) State Decal#: 6) Color: ��� FLgyIZS <br /> VEHICLE OWNER INFORMATION._ <br /> Name: EZ-69E5 <br /> Address of Owner. g GOIZDD(UE&06"(L CI °S� 21 2 Qg <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 /> offc �/�esult in permit revocation and penalties. <br /> � 2s� <br /> Si of Vehicle Operator Date <br /> COMMISSARY-INFORMATION . <br /> Business Name: atUfOIJ Clt 6 td(, TkUQ< C6A1M1Z <br /> Owner Name: 5&V60d W^ <br /> Site Address: S. USvS40� Sr S -CC L)(S G 9S O� <br /> 201 Street Address City <br /> Phone: ( ) .)--7 6--S <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 DStore frozen food ehicle wash facilities <br /> (2 or 3 compartments) <br /> ET'Preparation of food Q Hot&cold water for cleaning D<ollet&hand washing tore refrigerated food <br /> B/Store dry food/supplies rovide potable water Overnight parking Adequate electrical outlets <br /> s , 6 <br /> Si na ure of Commissary Owner/Operator Date <br /> (HEAL-TH DEPARTMENT,-'., - r i <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 />