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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): s 1 (UD H I LX6/9 A'7 <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate#: Cl 1 4) Year: 0C <br /> 4 <br /> 2) Vehicle Vin #:-7F`rk E Iq 5-H 0,�,0 ) Make/Model: �� <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: S i <br /> Address of Owner: LA c _ ,ml 0 ro X, C <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 resu tt inpermitrevocation and penalties. <br /> Si nature of Vehicle Operator Date <br /> CONI biISSARY INFORMATION <br /> Business Name: C 6 G' �' �� 0"� <br /> Owner Name: <br /> Site Address: 3 Sr f_- �� T S %v C lam'i o�✓ �' S`L� <br /> Street Address City <br /> Phone: 1'1 to <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 /> ❑ Liquid &solid waste disposal ❑ Utensil washing sink ❑Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food ' Hot&cold water for cleaning Toilet&hand washing —E� Store refrigerated food <br /> ❑ Store dry food/supplies ❑ Provide potable water Overnight parking Adequate electrical outlets <br /> �^ . � 'N GO TCE CREAM <br /> CJ_ \ l CARPENTER RD. <br /> ILL d,-Signature of Commis Owner/Operator Date ?ON,CA 95215 <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 />