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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all Information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION .V, <br /> Vehicle Name (DBA): CC C-7E L DE rf(,(T 5 R Q Gt u E Z <br /> Address for Vehicle: JI' S U t_ S I.. s'J O G tl1 �Q 10 o s <br /> Street Address City <br /> 1) License Plate#: T/uX(n3Z9 4) Year: oZ 6(5- <br /> 2) Vehicle Vin#: 5) Make/Model: C#/q/t/a <br /> 3) State Decal#: 6) Color: ,STEEL <br /> VEHICLE OWNER INFORMATION <br /> Name: ct EL MARCS D E <br /> AddressofOwner. 16ol E, TQrFEk56&l ST- ,Sc�CX A ?S020-"- <br /> Street address I 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 /> Rac��e\ f lore S 71Z / <br /> Si nature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: j [ (/W W,0 p <br /> Site Address: / —S , Wfl1fQA1 S%, c-rl <br /> Phone: �) �G f Set Address city <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 /> Q"Liquid&solid waste disposal Kl u nsd washing sink ELsCore frozen food 01 Vehicle wash facilities <br /> (2 or 3 compartments) <br /> Q Preparation of food194 of&cold water for cleaning oilet&hand washing E(-Store refrigerated food <br /> Store dry food/supplies E515rovide <br /> potable water vemight parking Adequate electrical outlets <br /> Signature of Commissa wner/O erator 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 />