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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): NJTQJ-1 -EQ-'5 Cj lAErt�SE <br /> Address for Vehicle: 2-332- T <br /> W41AI CT TWCY Gfl S376 <br /> Street Address city <br /> 1) License Plate#: ! /U/1�J�33 $ 4) Year: D C> / <br /> 2) Vehicle Vin#: 5) Make/Model: JPfl Cc <br /> 3) State Decal #: 6) Color: GREEAI <br /> VEHICLE OWNER INFORMATION <br /> Name: 1-501176e.. 2 A16RA CRUZ- <br /> Address <br /> UZAddress ofOwner. 332 IAI G /}GYCh95376 <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 permit revocation and penalties. <br /> 11IY « <br /> Si e ' e Operator Date <br /> ICOMMISSARY INFORMATION <br /> Business Name: IANIPCRT67RING U Cl/C C E fJ`rL <br /> Owner Name: -r -T-Ignnb <br /> Site Address: 7 7 S, I D ld ST. SToG 6 C- S20 <br /> Alpq Street Address city <br /> Phone: ( /) -Z `19- 5416 <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 Utensil washing sink <br /> (2 or 3 compartments) Store frozen food ET/VehiGe wash facilities <br /> E Preparation of food R(Hot&cold water for cleaning EP/Toilet&hand washing Store refrigerated food <br /> Store dry food/supplies L� rrovide potable water 2rOvernight parking Adequate electrical outlets <br /> /i hP <br /> Si nature 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 1"17 sots MFPU APPLICATION <br /> 7/1812008 <br />