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41. <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): \ii cloi \ Le_Txe. .7-01-A_-__ / (IA .: .-T4 co on ; 0 il a_e_ .--1-0 \ Iv LI 4 L. <br />Address for Vehicle:e)cs:c LAiel y <br />Street Address City <br />License Plate #: i-foosl -Nt 4) Year: c) 0 07 <br />Vehicle Vin #: 4.6t-l-k1(24.1-(-5 le) ,t.;(-( 5) Make/Model: C-tAedf44 S1 \v-N oLo <br />State Decal #: 6) Color: U.) <br />VEHICLE OWNER OWNER INFORMATION <br />Name: <br />Address of Owner:;15cs SrAlr-or-S- LA-)cky K,. CA . <br />Street Address 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 />Signature of Vehicle 0 erator Date <br />COMMISSARY INFORMATION <br />Business Name: do/q" 576ric9e, Opinn71:5,5-40.T .'P&4- Z.a_ 6int:5g _r /4_ iitiod,„ <br />Owner Name: Arturo Va.-CA, ,44 ttiele7 .•fie-- <br />Site Site Address: 570 9-14 54--, 5742_ D M ocitg-43, 6.4 . 9:536-3z <br />Street Address City <br />Phone: <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 />tensil washing sink Liquid & solid waste disposal Flitore frozen food V\--/ehicle wash facilities (2 or 3 compartments) <br />ErPreparation of food Pr-Hot & cold water for cleaning Toilet & hand washing [7;6tore refrigerated food <br />Store dry food/supplies VI-"rovide potable water yiernight parking 1equate electrical outlets <br />71714-0 '/"-dg' 5 . 9.• o2o / - <br />Sign„tu e 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 />e. 9. ‘,20/.q- <br />Signature of County REHS Date <br />END 16-017 <br />7/18/2008 <br />EXPIRATION <br />DATE 6 gai960 5 of 6 MFPU APPLICATION