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RECEIVED <br />SEP 25 2018 <br />VERIFICATION OF VEHICLE COMMISSA <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION PA 0 f) 1 34, 6-'7 FA-002g 209 <br />Vehicle Name (DBA): ckkA '7' op) 14) (15ELS <br />Address for Vehicle: 536o(../klivi,i 171 6 E /i u ,..-T-0 cg -ra fkj CA <br />Street Address 1 City <br />License Plate #: 3 7 p2.' ? 9 L ( 4) Year: ZO -O <br />Vehicle Vin #: 5) Make/Model: <br />State Decal #: 6) Color: G RE-EAl <br />VEHICLE OWNER INFORMATION <br />Name: 5 u H vi co 6 k s 1 1 \ ) 61 <br />Address of Owner: 5-35-0 lit-A 07(r/FGe AV. 5 TeGfC10 Ili C4- f--6-)1 6 <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 />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: Lz Afc 0 'kJ c__ A TIE- R 1 'Li e, -r-kuck _ 61,01-L-_-0z.. <br />Owner Name: ( 7 / 7 S, U Alf OA/ 61. 5 re) 04, TO Aj/ CA <br />Site Address: 5/11‘ 00 7. i ?deo <br />ZO <br />Street Address City <br />Phone:( (tr ) -2._ 9 ri- r _s-ce ( <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 />nsl 1-91.: ErUteiwashingsink iguid & solid waste disposal [lore frozen food ErVehicle wash facilities (2 or 3 compartments) <br />E6reparation of food Z7F----lot & cold water for cleaning F-Toilet & hand washing P;:(Store refrigerated food <br />r<tore dry food/supplies Provide potable water al‘emight parking 1equate electrical outlets <br />Signature o -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 REHS Date <br />Eilia0RmNMITEITRAL <br />VICES <br />HEALTH <br />END 16-017 5 of 6 MFPU APPLICATION