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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): -1-0\x_cg VI 0 R.. t:,_ G y RC) <br />,---- Address for Vehicle: %1 , g ab a/L/z4pce,•, 6q- 19-f c <br />Street Address <br />) <br />/ <br />I <br />a City <br />License Plate #: 546-3 2/ ?9 4) Year: 9 (" <br />Vehicle Vin #:epk. .% - 83 -.9z) c"-/ z o / 5) Make/Model: / i <br />State Decal #: /4- 6) Color: Mr1-111.41A<a' ' <br />VEHICLE OWNER INFORMATION <br />Name: <br />Address of Owner: /3 b?3 S'f e,t, <br />/ <br />. 462A-41 a7 /2/ 40 4 / / :41 Ci e cgla- , 2 <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 />, <br />--i 0 C i IC v--) . /G) — q -/7 <br />Signature of Vehicle Operator Date „. <br />, <br />COMMISSARY INFORMATIM <br />Business Name: Ile / 1 <br />eks4 , <br />1 Owner Name: , CA; ' i ( i' Jviteit vt,i) I <br />Site Address: pial) di-4-64---...,&-i as--,&0 C <br /> <br />Street Address -,--) City <br />Phone: (9(i13) giaZ(,- qc /262 <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 />ft Liquid & solid waste disposal q Utensil washing sink •Ti Store frozen food Vehicle wash facilities (2 or 3 compartments) <br />Ti Preparation of food Iti Hot & cold water for cleaning [1:I. Toilet & hand washing 7 Store refrigerated food <br />I I Sto dry ood/supplies laerovide potable /ter ij Overnight parking 11(Z' Adequate electrical outlets c , <br />'t <br />(1 <br />— - id — 11—( ? <br />' Signature of Commissary •wner/Opera ' 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 />EHD 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008