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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION / , , Vehicle Name (DBA): *s / , / / <br />Address for Vehicle: ,.;:, (6.7, k (../z, ) ell r-Cc-9 C- a:zi, <br />License Plate <br />Vehicle Vin #: <br />State Decal #: <br />Street Address --' City V <br />#:e....--' 5-8 q H 2.._ 4) Year: ZOO9 <br />564 OD 2,7k, 931:( pizzg 5) Make/Model: ( ev- g)ovi(Gicid( <br />)..6) Color: I <br />VEHICLE OWNER - . ATION ,INFO _ <br />Name: kal_ed, 4 <br />Address of Owner: 6,6 aZ 7 i . cAf-es&:ii, ijs---k,_ OW? <br />The mobile food facility shall <br />operating day for cleaning <br />discontinued, the permit <br />office m y result in permit <br />---P) <br />Street Address _21' ty <br />operate out of a commissary and shall report to the commissary at least once each <br />and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br />holder must notify this office to make the necessary changes. Failure to notify this <br />revocation and penalties. <br />2_011-- <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: 1 A,,lay)12 Owner Name: f., 1 „ , i _ <br />Site Address: i22.eV e tizi ›ktita,Mrsi e04 9c369 ‹: <br />Street Address -I City <br />Phone: 9,/j"-- 4 C71) <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 />Utensil washing sink i'1 Liquid & solid waste disposal fl Store frozen food K Vehicle wash facilities (2 or 3 compartments) <br /> Preparation of food .g1 Hot & cold water for cleaning Nj Toilet & hand washing Store refrigerated food <br />/ <br />fl re' dry food/supplies .Provide potable water Overnight parking A' Adequate electrical outlets , <br />,c9-2-bitce je-'7 RAI ffe)e-- <br />Signature of Corn issary Owner/ a or .117 Date <br />HEALTH DEPARTMENT <br />If the commissary/food establishment <br />current health permit by signing <br />County. <br />is outside San Joaquin County, the local health jurisdiction must verify <br />below. Commissary/food establishment is in <br />Signature of County REHS Date <br />END 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008