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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): , e 10 6371 k <br />Address for Vehicle: 7' , (3#i 9S-3 ° -C. <br />Street Ad. ress <br />t/c )2 <br />City <br />License Plate #: 4/5 G 95s---? 4) Year: 0 P. . <br />Vehicle Vin #: 4--/41q1010---16T56926 If 5) Make/Model: ii <br />State State Decal #: eyti 6) Color: 1.., / /1 w <br />VEHICLE OWNER INFORMATION <br />Name: 4 ) I aj_h_ .4/2= <br />Address of Owner: y4/:5 -- _5, l-e--Q—' qii ‘i ,75 / aVZI ' 1647 r579, gf) i ...- 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 />office may result in permit revocation and penalties. <br />Signature of Vehicle Operator Date -. <br />COMMISSARY INFORMATION <br />Business Name: 'i_ Cx C.0 MQ:c C, \ O. \ COS. ?CA'\on <br />Owner Name: C51 . R. C_\(-\•, c) '' i\c .,(\2,-k-k c. ." <br />Site Address: 2CA 00 e,. KO\ca-N (\C)'kAZ..\.. o c o ...kn CA q52%)c) <br />-I 1 Street Address City <br />Phone: (20-1) (,-1 V\ • i-k 510 <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 c NI Liquid & solid waste disposal n Store frozen food K Vehicle wash facilities (2 or 3 compartments) <br />I I Preparation of food X Hot & cold water for cleaning K1 Toilet & hand washing Store refrigerated food <br />/„. pi Stor food/supplies A Provide potable water N Overnight parking X_ Adequate electrical outlets <br />7 - , ; ? <br />Signature of Commi ary Owner/Operator Date <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 />END 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008