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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): g Ey) r---- R 0 (.) <br />Address for Vehicle: 16 i 5b rit-;' 0 EPEi OCitice 4(2 LtinwP fi 25i3° <br />Street Address City i <br />-----7 <br />License Plate #: 2,51 v01/ 7 4) Year: 2. 0 C 0 <br />Vehicle Vin #: 5) Make/Model: Pt) <br />State Decal #: 6) Color: G t:_ECI\"/ <br />VEHICLE OWNER INFORMATION <br />Name: ke i‘3. <br />Address of Owner: 16 1 5 c) j_--N 0e. ?iv z /TR Rot) c 4 (75 33 6 <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 permi revocation and penalties. j <br />Signature of of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: ii ii/ 1 c-c3 21-1--EK/(../j 6,-_ 7W c t c fr...._ <br />Owner Name: <br />Site Address: / 7 i 7 ‘,..5 , et iv c 0 c-,2 5-1-- 51E-9 c kre ('L) _-,_ 4_ 9 2_0 4 / <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 />rkiquid & solid waste disposal tensilwashing sink [Zi‘re frozen food I-Vehicle wash facilities (2 or 3 compartments) <br />[t<eparation of food E -ot& cold water for cleaning n oilet & hand washing Firtore refrigerated food <br />Store d ood/supplies R r.:)vide potable water I-.)vemight parking R<Iequate electrical outlets , <br />/ <br />Signature of Commissary Owner/Operator ate <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 <br /> 5 of 6 <br /> MFPU APPLICATION <br />7/18/2008