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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): --Tams 14 OA a <br />Address for for Vehicle:aiikkiay /1.6 cedo ,,,_ 64, q c 3 ? J <br />Street Address tity <br />License Plate #: 9 •c-65' 5- td/ 4) Year: / 97('2 <br />Vehicle Vin #: -TP/- %403 fod5q905) Make/Model: ( in& <br />State Decal #: 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: si hp' a 1 - Address of Owner: 0/ - gi d-O Ee/a/O IA 1 C4 q. 13 ao <br />Street Address U 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 />disconti • he permit holder t notify this office to make the necessary changes. Failure to notify this <br />offic: i7 n permit rev. ation :nd penalties. . <br />.., <br />.1! a ure of V•hicle Operator Date <br />COMMIS • RY INFORMATION <br />Business Name: Lc? 6 5 . , , 1 ,,_-. 5 - a ,--, 27/fr / Ades-7-cf) <br />Owner Name: G di a 6-,/ _S" s p t 4 s - 7 <br />Site Address: .5-00 714 _574 frieriejl-c, ?_.s. 3 3 y <br />Street Address City <br />Phone: (2)07) 33,9/36" as <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 />Liq Utensil washing sink uid & solid waste disposal -17-ctore frozen food K<cle wash facilities or 3 compartments) <br />P<Dreparation of food Hot & cold water for cleaning _.,,-'...--1-oilet & hand washing f ";-tore refrigerated food <br /> Store dry foo•—upplies ../P .vide table water I I Overnight parking .12<71equate electrical outlets <br />, j <br /> <br />ISPO' /Lfif, . /1/4077$5 <br />g ur- of Commissary Owner/Operator Date <br />EALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local he. Ith jyrisdiction must verify <br />current health permit by signing below. Commissary/food establishment is in A vx t S .... <br />County. •-• 11./A: <br />\ / 3 0/ t 6 A1i# 1.4.4.a16.. <br />Signature of County RENS Date <br />EHD 16-017 <br /> <br />5 of 6 <br /> <br />MFPU APPLICATION <br />7/18/2008