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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION r <br />Vehicle Name (DBA): , 0.221 /0 <br />C/W / Address for Vehicle:‘c;,Z- e?,..yl)h/T dei z,' i ?kb;, ex-- / C4,1 9.,•:-b-0,- <br />' Street Address il i - City <br />License Plate* 4 H'SVOI 4) Year: <br /> <br />cA 01 81 <br />Vehicle Vin #: qfrigin/F417,75illie)49 5) Make/Model: Noe <br />State State Decal #: Ci_ izi- 6) Color: <br />VEHICLE OWNER OWNER INFORMATION <br />Name: (10-71LL, p livit ,r, ivi , - <br />Address of Owneri 6-----cAr X.‘,611- 4.A. 66_z_el i-, <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 />offic- result in vocation and penalties. <br />------ //7 4 <br />Sig ature V erator Date <br />COMMISSAR NFOR7TION <br />Business Name: ,/;(. iet <br />t / t Owner Name: - i /falufit <br />Site Address:' a)V116 t' 4 1 te-Al <br />Street Address (/ / city <br />Phone: 03061)21&Li -/.1 ---7). <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 />6 <br />N z „ <br />I Liquid & solid waste disposal ji Utensil washing sink 1 I Store frozen food 0 Vehicle wash facilities (2 or 3 compartments) <br />....._ Preparation of food [1 Hot & cold water for cleaning 0 Toilet & hand washing n Store refrigerated food <br /> S re ry food/supplies '' g Provide potable ater —Overnight parking E Adequate electrical outlets <br />, <br />/9---/r <br />Signature of Comm'ssary Owner/0.- - . [Ate <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 REMS Date <br />EHO 16-017 <br /> <br />5 of 6 <br /> <br />MFPU APPLICATION <br />7/18/2008