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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> ;VEHICLE INFORMATION. <br /> v <br /> Vehicle Name (DBA): (3W(,5 &kms QUP 64 <br /> Address for Vehicle: G b I/��/J�t� C T6` TO of 9 <br /> S reef AdDDdress '+ City <br /> 1) License Plate#: 4) Year: "26 1 g <br /> 2) Vehicle Vin #: 5) Make/Model: Mfij I UP <br /> 3) State Decal* 6) Color: /` � fLfIY1Z�S <br /> VEHICLE OWNER INFORMATION <br /> Name: LD RE.5• C P-0 S MPE Z - <br /> Address of Owner: 13 GOk-bblq (Z58416R- CI i TOGL7 p 2 <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 &r 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 /fesult in permit revocation and penalties. <br /> 2s4 <br /> Si of Vehicle Operator Date <br /> .COMMISSARY INFORMATION . <br /> Business Name: VANA) C 6 1AI(; 1-kYCl< C6AITS6- <br /> Owner Name: 5&—V l 6R RA O <br /> Site Address: CD7 ,s. LA W56 ► S�• srt oc ant 95 0)::; <br /> Street Address City <br /> Phone: (2�) ,L 7 6--S l ii <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 /> [5-'Liquidp&solid waste disposal Utensil washing sink [] �(2 or 3 compartments) u More frozen food ehicle wash facilities <br /> Preparation of food E Hot&cold water for cleaning Toilet&hand washing tore refrigerated food <br /> tore dry food/supplies rovide potable water PrOvernight parking Adequate electrical outlets <br /> Signal-re of Commissary Owner/Operator Date <br /> HEAL-TP'D,EPARTMENT „r F' <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 RENS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />