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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> B74 <br /> V0 INFORMATION,:;' <br /> Name (DBA): Aes 1 G PJ r_— Do GS <br /> Address for Vehicle: X352 lZoofls—) ER r1 Tonl C 0 <br /> Street Address city <br /> 1) License Plate#: qj)kl(,15 2-'q 4) Year: <br /> 2) Vehicle Vin #: CA 9 ,(q-612_ 5) Make/Model: V4 P f6D <br /> 3) State Decal #: 6) Color: <br /> 71-Ejillmt,OWNER' AT <br /> Name: <br /> -T-R c li s <br /> Address of Owner: .5T-R CAM <br /> �S 1�-,C-K-Fb C 4 <br /> StreA�Cr,�P' 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 result in i3ermit revocation and penalties. <br /> Signature of Vehicle bperator Date <br /> Business Name: ND A] IIJ 6- -rR CA C ze�/1)76-A- <br /> Owner Name: <br /> Site Address: / 7/ 7 <br /> .20? <br /> Street Address city <br /> Phone: (. - ) -5�4� <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 /> [E/Liquid&solid waste disposal E&�tensil washing sink <br /> (2 or 3 compartments) tore frozen food ED'/Vehicle wash facilities <br /> [D�Preparation of food �ot&cold water for cleaning EK01let&hand washing �Store refrigerated food <br /> E2's'tore dry food/supplies [],Krovide potable water Qz0vernight parking [:rAdequate electrical outlets <br /> Signature of Com missal"y Owner/Operator Date <br /> HEALTHI DEPARTMENTAMM <br /> A, <br /> w" <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 RE HS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7118/2008 <br />