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Preparation of food Hot & cold water for cleaning <br />St dry food/supplies Provide potable water <br />Signature of Commissary Owner/Op ator <br />; ',.i-1112AL 'I V1 <br />Liquid & solid waste disposal Utensil washing Sink <br />(2 or 3 compartments) t 6 El Store frozen food Vehicle wash facilities <br />Toilet & hand washing Store refrigerated food <br />Overnight parking Adequate electrical outlets <br />Date <br />VERIFICATION OF VEMCLE CaWiNISSART <br />Please provide all information requested. An incomplete application may delay approval. <br />rgEHICLE ii\IFORMATIOM <br />/2 1 Vehicle Name (DBA): fTJ <br />Address for Vehicle: 2/2/6e,, <br />Street Address /-1 City <br />License Plate 0: /IX V2 ;( 4) Year: <br />Vehicle yin #: / 9v11:0e.,2)50 2./.9 5) Make/Model: <br />State Decal 0: CY4 ._Y- 6) Color: <br /> <br />Lai-XL/oesitao <br /> <br />'VEHICLE OWNER ONIFOIRMATION <br />Name: <br />Address of <br />Ti 3,67- <br />1) (6)). ,/-,c; 7/2 <br />Street Address <br />Or. er: <br />JKYW--/ <br />) ?CV ,?<0 <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 (ealeccie 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 mat esuJt permit revocation and penalties. <br />- <br />Date <br /> <br />- N..- <br />;! Ak..71 - R. " C Nr-,:, <br />i Site Address: 7c\ 00 cL.IA dca\ (\ç3 WCA,,i ; I - . Street Address i <br />i Phone: (20,A)fe‘ (.0L4t - i-A 510 <br />i " the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my i ry <br />—/ x <br />8ignature 6f Vehicle Operator <br />L-011EfilSSARY . <br />Business Name: <br />Owner Name: <br />-ocrw <br />f:C(. <br />, okouiLkon CA (3520 <br />City <br />commissary as checked below: <br />if the commissanfifooci 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 />Coun <br />3 Signature of County RENS Date <br />EHD 16-017 <br />711812006 <br />5 of 6 MFPU APPLICATION!