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v v� <br /> VERIFICATION OF VEHICLE COMMISSAR Roy <br /> Please provide all information requested. An incomplete application may delay appy ?419 <br /> `�M�FNTAC <br /> VEHICLE INFORMATION CES Ty <br /> Vehicle Name (DBA): <br /> Address for Vehicle: / Yzr ,v_ rn,.r-(c,e 'j � 1� 5,e,.r <br /> Street Address City <br /> 1) License Plate #: Co F9 q 5`L (e 4) Year: zdoLt <br /> 2) Vehicle Vin #: (6-z4psyym 3 3 o z3 5) Make/Model: �P-� <br /> 3) State Decal #: Z47Gn�K 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: i <br /> Address of Owner: <br /> Street Address VCity <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 resu t in permit revocation and penalties. <br /> Signature of V044 Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: r't-i5 -8 p� <br /> Site Address: /y ZS /j/ ryl��-k-��— /��. , 3 S fr �- <br /> Street Address City <br /> Phone: ('51 ) 7�,y—oLt L- <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 /> aLiquid &solid waste disposal Utensil washing sink(2 or 3 compartments) Store frozen food Vehicle wash facilities <br /> Preparation of food ®Hot&cold water for cleaning Toilet&hand washing ER Store refrigerated food <br /> Store dry food/supplies Provide potable water Overnight parking �Adequate electrical outlets <br /> Si nal(fare of Commis ary Owner/Operator Date <br /> HEALTH DEPARTMENT "k 77r <br /> ` <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 �cvi rump of z C i , <br /> Coun��� <br /> Signature of Co HS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />