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J <br /> VERIFIGAT[O N OF VEHICLE COMMISSARY <br /> Fisas°e provide sit Informaticn requested. 4.11 iibcrit"Plete application may delay approval. <br /> Vehicle[dame(DDA): � � „ � tj C'�e f <br /> Address for Vehicle: ?z E RD , :STW AP (f l <br /> Street Address City <br /> I) License Plate#: 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model.: <br /> 3) State Decal-#: 6) Color: <br /> Ef i C ire Ep €c rc�R RVATO r. <br /> .C'l=E-il�r�le.�F�l:_�C'c.. t1_c Citi��r-cf:�_lF <br /> Name: �i ; i: L ,) L <br /> Address of Owner: , ) 7 C- S'3"7 <br /> Street Address city <br /> The mobile food facility 11 operate out of a commissary and shall report to the commissary at least once each <br /> operating day fo ani and servicing (CalCode sections 114295 & 11423-7). if the use of the commissary is <br /> discontinued, t erm! aller must notify this office to make the necessary changes. Failure to notify this <br /> office may res t in ESE , rev cation and penalties. <br /> /.2,4 <br /> Signature of V tor Rate <br /> - <br /> Mi rI B ',RY, I I F n r 7 <br /> Business fume: , .l e U C — <br /> Owner Name: _5� -7- � ¢'r� �;` r � , 1 ' <br /> cite —A rIrirvec• 't s> oF-V ff . .r7(!E- <br /> YY - rt ...._ <br /> evil Q4 ( Q\ <br /> Street Address City <br /> Phone: (a-,(1) <br /> 1,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at€cty <br /> commissary as checked belov ::�� <br /> F-1Liquid&solid waste disposal L--1 Utensil washing sink Store frozen food Vehicle wash facilities <br /> (2 or 3 compzrtments) <br /> ❑Preparation of food Hot&cold water for cleaning Toilet&hand washirig <br /> Store refrigerated food <br /> ❑ C4. <br /> Store dry food/supplies ❑Provide potable water �.Overnight parking Adequate electrical outlets <br /> r ' GO ICE CREAM <br /> �j-. � ' r TAT r ti II�EI�'' R RD. <br /> " <br /> Signature of Commissa Owner/OpL,erator Date r*rf: rr N --A 35245 <br /> HEALTH.QEPf- R 1 EVI-EWT-- <br /> lf the commissary/food establishment is outside Sacs Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing beiotrk,. Co:nmissaryrfood establishment is in <br /> County. <br /> Signature of County RE HS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />