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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): I O, S rj(a v\ <br /> Address for Vehicle: 5\ OA50 GWG �EilLv111 GAY `7 <br /> Street Address r City t <br /> 1) License Plate#: –71-772X <br /> / I�2X 1 4) Year: �\ <br /> 2) Vehicle Vin #: I(�P `1�-13Z-eCT 3 "S 5) Make/Model: -�0(i /2,V\ <br /> 3) State Decal#: (/j&c 6) Color: k,WW4AU <br /> VEHICLE OWNER INFORMATION <br /> Name: a)i V\ Iw)a D – <br /> Address of Owner: 6k Wso � 41 <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 /> oper Tng day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> dis on , the permit hol r must notify this office to make the necessary changes. Failure to notify this <br /> off a ay result i ermit r cation and penalties. <br /> o/ <br /> S of Nehi6le Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: q7iku <br /> Owner Name: 0awSK h <br /> Site Address: R 0 D I V A ' 5$1K <br /> Street Address city <br /> Phone: ) <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 'L—I Utensil washing sink Store frozen food .E Vehicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food Hot&cold water for cleaning ilei&hand washing Store refrigerated food <br /> Store dry food/suppliesProvide potable water {J overnight parking Adequate electrical outlets <br /> Sina u mmissa Owner O erator Date <br /> HEALTH EPARTMENT <br /> If the commissary/food establishme uts' a San Joaquin County,the local health jurisdictiqc��3 must verify <br /> current health permit ing bel o missary/food establishment is in Sperct tlt4 .76 �7j <br /> Cou ty <br /> Z� I <br /> Signature of Co y5 <br /> Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />