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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> V6 019443 W&R,06 <br /> Vehicle Name(DBA): cSW>-W ice CKE-W'A <br /> Address for Vehicle: 3-599 E:- FW r-F N TE:R R 7 o CA<-7 C V) - q I <br /> Street Address city <br /> 1) License Plate#: (�zRA(637 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: r©R JJ <br /> 3) State Decal#: 7-S16) Color: <br /> VEHICLE OWNER INFORMATION , <br /> Name: AM L) <br /> Address of Owner: q S C4 qp7 &Z <"700A( <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 /> -? L VIA G t-t <br /> Signature of VehicleOperator Date <br /> COMMISSARY'.1NF,0-RMATidN,-7'&W <br /> Business Name. r\ <br /> fV C7 0 r" P,(:F- 1� cy? <br /> Owner Name: S-14 C-7 IV) <br /> Site Address: -2 C-14 <br /> Street Address city <br /> Phone: -- / '--,7 (4 <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> F-1 Liquid&solid waste disposal E] Utensil washing sink Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> F] Preparation of food Hot&cold water for cleaning -Q Toilet&hand washing Store refrigerated food <br /> F]Store dry food/supplies ❑Provide potable water Overnight parking Adequate electrical outlets <br /> pTCT�'N GO ICE CREAM <br /> CARPENTER RD. <br /> Signature of Commissary Owner/Operator Date CA 95215 <br /> HEALTH ft MENT,1,: <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 RE HS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7118/2008 <br />