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� 9 <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name(DBA): 6 LE <br /> Address for Vehicle: Z20 E 50rlD Sr <br /> ZQGrela. C4 S�o <br /> Strm Addrrm City <br /> 1) License Plate#: 4k8763 8 4) Year. 2 ®O r <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 6) Color. <br /> VEHICLE OWNER INFORMATION <br /> Name: EyK Al <br /> Address of Owner: 2.Z pa CA 95,2 <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 & 114297). If the use of the commissary Is <br /> d1scontiflued, the permit holder mustify this office,to make the necessary changes. Failure to notify this <br /> office y result in permit rev and penalties. Z <br /> rl C57/3 <br /> SKr ature of V cle OjArator Date <br /> OMMISS Y INFORMATION 1 <br /> Bu <br /> sin ame:: opjGf} C 6 (, U,C ( —Q <br /> Owner Name: <br /> Site Address: 5 - IIA11,91V ,S(TD Q/-I G5 vZD L <br /> Phone: ( <br /> �y) g 7 bM A/6 \ J cnr <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 viensil washing sink �jore frozen food Ej-�ehiGe wash facilities <br /> (2 or J comparsnems) <br /> reparation of food Q<ot&cold water for cleaning ,,.EJToilet&hand washing E Store refrigerated food <br /> Store dry food/supplies al�vlde pot water n6�mig t parking LKNa'equate electrical outlets <br /> - <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 /> r <br /> EHD 16-017 50r8 MFPU APPLICATION <br /> 7118/2008 <br /> .N' <br />