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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): CL © P <br /> Address for Vehicle: 0 c(Aj !A1).,$'/,/)E e 9S2OS <br /> Street Addresscity c! <br /> 1) License Plate#: 197-$716 4) Year: PC <br /> 2) Vehicle Vin#: 1-0I2-(A Ob"jXYZ00I L05) Make/Model: oAN G <br /> 3) State Decal#: 6) Color: sTd-f l/GE� STEE/_ <br /> VEHICLE OWNER.INFORMATION <br /> Name: R C-41 (7 <br /> Address of Owner: 54kW S E 4116. 57-01 C ty Q5Z45- <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 /> office may result in permit revocation and penalties. <br /> �S <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: Y&04J C 7-6CQVT6k <br /> Owner Name: `1/ 0 <br /> Site Address: S. a COA) Sr <br /> n Street Address City <br /> Phone:©� o9C 29 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 /> 4jeiquid&solid waste disposal tensil washing sink Store frozen food !. Vehirle wash facilities <br /> (2 or 3 compartments) � � <br /> eparation of food I oot&Cold water for cleaning �roilet&hand washing Store refrigerated food <br /> ore foodl u lies 041rovide potable water veinight p rking L/dequate electrical outlets <br /> _4 - z s <br /> Si nature of Commissary 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 />