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VERIF11CATgONOh VEHMLE CONRIOSSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHLIPLE DRFORWATION. <br />Vehicle Name (DBA): <br />61- 950057-7 <br />-City <br />cE-40 License Plate #: 75-45-- 4) Year: <br />Vehicle Vin #: IG el/R.3oz /id/ 03.1,5) Makeffillodel: <br />State Decal ft: ..6) Color: <br />'VE-igCLR.Oft9NElliViORFIRA11.6N1--. <br />Address for Vehicle: T•trii-etexi te)4,ti <br />Slett Addmss <br /> <br />Name: a}z_vnA, <br />Address of Owner: <br />Street Address 1 / city ) <br /> s <br />The mobile food facy shall °pate out of a commissary and shall report to the commissary at least once each <br />Qperating day •for cleaning and servicing (CalCode sections 114265 114297). if the use of the oornmiseary 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 revosaUon and penalties. <br />‘- <br />„ . <br />6sP:6\. (A-VetDi Signature of Vehicle Opera-for" <br />COMISSWITIVORilliATEON... . <br /> 4 <br />c\.\ c --so ck <br />70 00 '\AxA' o tr <br />Business Name: <br />Owner Name: <br />Site Address: <br />rk D <br />R. t'Urc-)" Pck-k c. <br />Street Address <br />Phone: (20A) le\ (O- <br />!, the commissary, owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />Citlr <br />Utensil washing sink <br />(2 or 3 compartments) <br />Provide potable water <br />0 Liquid & solid waste disposal <br />0 Preparation of food <br />s. <br />(e dyy food/supplies <br />t, 0 Store frozen food <br />. -9 —/ce, <br />Vehicle wash facilities <br />0 Store refrigerated food <br />Adequate electical dutlete <br />Hot & cold water for cleaning LJ Toilet & hand washing <br />E Overnight parking <br />Signature of Commies Owner/0 erILuI Date <br />F4Pc`1,74 DEPARTMENT <br />i If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />current health permit by signing below. Commissaiyifood establishment is in <br />,1 0 o u n ty . P a e <br />3 3 <br />Signature of County REHS Date <br />5 of 6 MFPU AFPUCATIOM EVID 16-017 <br />171612008