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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): '-Zki f e-OA;; <br /> Address for Vehicle: Z <br /> Street Address City <br /> 1) License Plate#: / jC,y _ � i 4) Year: / 9 G/ 7 <br /> 2) Vehicle Vin #: ZA 'yC £2`Z_ Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name;, <br /> Address of Owner: G c r <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. <br /> Signature of Vehicl Operator Date <br /> COMMISSARY INFORMATION <br /> Business NameAUROP41 I q CAT F-1IQ- D K 1 tE— AAJP SERI.i <br /> i <br /> J Owner Name: " <br /> Site Address: 2L410 'C" 16o V <br /> Street Address City <br /> Phone: (2Cq) -qa <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 /> Q Liquid&solid waste disposal ❑ Utensil washing sink Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food 2/Hot&cold water for cleaning D/Toilet&hand washing ❑Store refrigerated food <br /> tore dry food/supplies [�"Provide potable water ❑✓Overnight parking C1e94CQb13WAtQ19EF1i 'v'J <br /> /"�o <br /> SUPPLY FOOD AND SER ICE <br /> qc2440 S.AIRPORT WAY <br /> iSTOCKTON, CA 95206 <br /> Signature of'Commissary Owner/Operator Date q . <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 />