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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): ' --( \--0' ' Lci -----06‘ : <br />Address for Vehicle: (0 10 s . .-..,,,c0a,cc\m_to ..)\ 1 _ <br /> <br />_, ,--- C-fs‘ q sz4 0 . <br />Street Address C <br />License Plate #: CO \M —1 'I 1 69 N Year: 2-DOS <br />Vehicle Vin #: Zi .07_ to-\ e 6,14,752-,cgc511. Make/Model: ."-T mil <br />State Decal #: 6) Color: R.-e6 • <br />.. . . . <br />VEHICLE OWNER INFORMATION , <br />Name: \V\ (1,6 0 NV) 040 <br />Address of Owner: C\ o CMck‘ 0:,,c (-).,_ ay,.k.U\r\ 1 C • <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 r It in permit revocation and penalties. <br />a O t-1 t -2_n 1 t b . <br />Signat re of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: 1\ a4 ,,c&_ (7a440,7,_: <br />Owner Name: IQ 1 eio,,,„__. , to 6 6-1,104L <br />Site Address: 6 7 .0 5 acrci_v0,40 ._s- L e.) P i _c- <br />Street Address City <br />Phone: (261) 7,(2_— 6 20.5 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 />/ <br />i <br />rq Liquid & solid waste disposalUtensil washing sink Store frozen food Vehicle wash facilities <br />(2 o ,compartments) <br /> Preparation of food Hot & cold water for cleaning Toil t & hand washing I I Store refrigerated food <br />re dry food/supplies Provide potable water Overnight parking I 1 Adequate electrical outlets <br />7 — T-7 <br />Sign ure of Commissary 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 RENS Date <br />END 16-017 <br /> 5 of 6 <br /> MFPU APPLICATION <br />7/18/2008