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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): E L AM- <br />Address for Vehicle: CA 95- <br />Z0 <br />Street Address City <br />1) License Plate #: 6 7 22 L 1 4) Year: q $u57 <br />2) Vehicle Vin #: 5) Make/Model: 1-(E f) R0 LET <br />3) State Decal #: 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: G6PJ Z R LO a V 04 <br />Address of Owner: 511 SMLFM WAY S G CA' S O 7 <br />Street Address I city <br />The moblie 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 114296 & 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 />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: ((NIDA) C R//UG 7-RGfcK CFi E.t� <br />Owner Name: S 4fiX ,4e 8 <br />Site Address: / 7 S lei ON s�kTo��,' pSoz o 6 <br />Street Address city <br />Phone: i �) a ff - 521/ <br />1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below:: -t/ <br />Q Liquid & solid waste disposal `IJ' �&nsii washing sinkore frozen food E4-Gehicle Wash facilities <br />r�y(2 or 3 compartments) <br />Q Preparation of food E riot & cold water for cleaning /Toilet & hand washing !'Store refrigerated food <br />Ea'S-�tore dry food/supplies 2Provide potable water DOvernight part ing EJIGequate electrical outlets <br />�3 .1 <br />Si nature of Coryinirssary 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 />EHD 18-017 5 of 8 MFPU APPLICATION <br />7118/2008 <br />