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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 (DBd .E S lilo c©Al E F!9 cTo TG . <br /> Address for Vehicle: 50o <br /> Street Address city <br /> 1) License Plate#: /S/ Y6p6- 4) Year: 2001 <br /> 2) Vehicle Vin #: 5) Make/Model: fi WIC IV S' <br /> 3) State Decal#: 6) Color: STd/fi)Z45S STEEL <br /> VEHICLE OWNER INFORMATION <br /> Name: ffLR12)XAJ EZ RV616 rUR E <br /> Address of Owner: 5-bio wUG. 'k© l 6/9 <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 result in permit revocation and penalties. 7 <br /> 9 m� 3 / 7 <br /> Si nat Vehicle Operator O Date ( / <br /> COMMISSARY INFORMATION <br /> Business Name: "lloelG 7—� !(/C, 7W tZ e CCN Ek <br /> Owner Name: Q a <br /> SiteAddrress: 179 ,!L c1AI/©AI C4kr,91 9S�764 <br /> A <br /> / �S ✓ d�b City <br /> Phone: �9 <br /> 1,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: r <br /> . IIquid&solid waste disposal 0-diensil washing sink <br /> 12 or 3 comparlmeM51 tore frozen food [A-<ehicle wash facilities <br /> E Pre aration of food Store of&cold water for cleaning Toilet&hand washing refrigerated food <br /> Store d ood/supplies Provide potable water Q O emight parking Q�equate electrical outlets <br /> 3 / <br /> Sign ature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health Jurisdiction must verity <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 /> I' <br />