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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name (DBA): 11f t)24F1F.Irle-WRI f&,(151AZr 27 Z <br /> Address for Vehicle: 2 2 2Z E IVI A(111- s7- <br /> J"toc/C JoAl. C-# 952 0 <br /> Street Address City <br /> r&t7- R 7- <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> Ai A" A <br /> W <br /> Name: jpkGE <br /> Address of Owner: <br /> 7/7F 67' UTC QA/ Gd -,Z 6 <br /> Street Address <br /> 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 /> ti—OALE MCAJOEZ (�4PMklfAtA. <br /> Signature of Vehicle Operator Date <br /> 'WS <br /> 1�' CAURY '4n <br /> 10 &1#0"§R�U&M <br /> Business Name: <br /> Owner Name: S19LOMM <br /> Site Address: / 7/7 S, WDI� 57- 5-TbCkEon) C4 &, 2-64 <br /> Street Address city <br /> Phone: <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 /> 03 <br /> 2T(tonsil washing sink'Liquid&solid waste disposal (2 or 3 compartments) 2store frozen food 'Vehicle wash facilities <br /> /Pre <br /> ration of food EBHct&cod water for cleaning dToilet&hand washing YStore refrigerated food <br /> Store dry food/supplies ��Provide potable water DOvernight parking PI-Adequate electrical outlets <br /> 02 -ZA 6) <br /> Signature of Commissary Owner/Operator Date <br /> �sm, <br /> m <br /> 3gxxff�y •e <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 /> I Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 711812008 <br />