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Sto <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE,INFORMATION,`,:.. <br />Vehicle Name (DBA): 1 CE SAM <br />Address for Vehicle: Cb 0 2Q f <br />Street Address <br />city <br />1) License Plate#: 4G W 5 2g 4) Year: <br />-Zpc 3 <br />2) Vehicle Vin #: 1G c&,c,1 a5V if3120g0g4) Make/Model: <br />CjaE7V 32\1 <br />3) State Decal #: 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: f� (} A <br />Address of Owner: <br />V-) <br />Street Address <br />city <br />The mobile food facility shall operate out of a commissary and shall report to the <br />commissary at least once each <br />operating day for cleaning and servicing (CalCode sections 114295 & 114297). <br />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 />�' As /r100 Z 2� <br />Signature of Vehicle Operator Date <br />COMMISSARY,INFORMATION ..... . . . ... . ... .... <br />Business Name: 5 k S V jt)l 'LCJP CjItCAW <br />Owner Name: �. <br />1� nn ee� <br />Site Address: N. wPSl.t SVt"%e Y\ <br />v�ft <br />r�t Oyl <br />° Street Address <br />city <br />Phone: (21j") (p <br />t e 1�7VYI1C7990�and will provide the necessary facilities for the above <br />California 95205 �_TT <br />mentioned vehicle at my <br />Stockton, r� sil washing sink Store ozen food <br />❑ Lic(r�_I_ � e disposal <br />Vehicle wash facilities <br />lr209yl) compartments) <br />7Hot <br />hand washing <br />❑ Preparation of food cold water for cleaning7vernight_parking <br />❑ Store dry food pplies ❑ Provide potable water <br />❑ St a refrigerated food <br />Adequate electrical outlets <br />2 2 <br />- <br />Si nature of Commissary 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 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008 <br />