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VERIRCA VON OF VEHiC_E COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA):1_6( 147,17:1- <br />Address for Vehicle: --7...),( <br />Street Address Address City <br />License Plate #: 1/4 11 / 4( 9 4-( 41 Year: / ? 5. C <br /> <br />dr sr( Vehicle Vin #: if c/,‘ p 3.,1 mg 6'7? 3 Z ) Make/Model: C77/6-- V <br />State Decal #: (../ fk \ f()4y1:1 .. 6) Color: 1.4; ii / /—C- <br />VEHICLE OWNER INFORMATION <br />Name: AL " _c / jrki, 4 //),- <br />Address of Owner: 0 C /z____:-//c. ,/y_ Li_ Al 6 1::- 6- /17 I- Chi , r63 ,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 />C.-Z-,./2t-:--2-7-Z. L, 5-- 3/ <br />Signature of Vehicle OperAfOr Date <br />COMMISSARY INFORMATION 1_ 19 5') f eyiro <br />Business Name: Name: 4 .i. 5 p e 2-. C 2"---- <br />Owner Name: e„ hic ,,h ,,,, <br />Site Address: ',1, 3 1 ,c._.5 ,,;74 c i.g_ ,04:-...,,/ 0 • 5 74 1-cei 1 . c'/•4' C , <br /> <br />Street Address City <br />Phone: (051) 5- / .7,3 6* .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 />sinkhi il —/- washing Liquid & solid waste disposal Utensil Store frozen food 171 Vehicle wash facilities 12 or 3 compartments) <br /> - <br /> Preparation of food 7 Hot & cold water for cleaning Toilet & hand washing '1 Store refrigerated food <br />7f Storedry food/supplies 1.--Provide potable water I—Overnight parking FrAdeguate electrical outlets <br />(-2.-1-q) OF C -' 3 ( - /R _ <br />gnature of ommissary 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 />El-ID 16-017 <br /> 5 of 6 MFPU APPLICATION <br />7/18/2008