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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION.A,,,,,„ <br />Vehicle Name (DBA): -1" Q5 ikiLbY (..-t_ 1 6t <br />Address for Vehicle: 6.2 0 5 , _`-2 ,c_vCt ‘A...t_ev\z‘,0 - . • q•S,PLIC Street Address City <br />License Plate #: t ,)( 6 7(..),C) 4) Year: 1996 <br />Vehicle Vin #: 1 Lib iiP.3jui 1-325) Make/Model: C hfirt) y <br />State Decal #: 6) Color: Ec_ct <br />VEHICLE OWNER INFORMATION <br />Name: <br /> <br />Address of Owner: 0,---s, it i t(64 '7 r),y- :-# <--, k Street Address PIA* C R__ • 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 discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office may result in permit revocation and penalties. <br />\ ''Yvl_C,•0,'\,. <br />Signature of Vehicle Operator Date <br />COMM!SSARY INFORMATION <br />Business Name: 0 j:5' 5 /A Ry Az-t---f L,,k, Owner Name: <br />' IP Site Address: ze L-.). , s zcz. r ztivi r , _f-6) ix) j 1• ' C1 3 5-24 Street Address <br />City Phone: ( 2 1 6:- 6 <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 />il washing sink [Ti Liquid & solid waste disposal H Utens was <br />I j Store frozen food [Ti Vehicle wash facilities (2 or 3 compartrnents) <br />I I Preparation of food — Hot & cold water for cleaning 7 Toilet & hand washing 7 Store refrigerated food <br />— H Store dry food/supplies 7 Provide potable water Overnight parking I I Adequate electrical outlets <br />.4, ... „, 'I, <br />/7 <br />Signature of Corn missary Owner/Operator Date <br />HEALTH DEPARTMENT S <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 RE HS Date <br />END 16-017 <br />7/18/2008 <br /> 5 of 6 <br />MFPU APPLICATION