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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): 60 iy-azaje / 6-pra virvii--) (1 '-e6k' [-Yea(' ( Address for Vehicle: 2goO z.-=' #a"61-6-2,9u-t2A- --0-foc_c<tc_‘-, 4_1 e-k.2c5S-- <br />Street Address City <br />License Plate #: 4) Year: Fict 6 <br />Vehicle Vin #: /4 /)2 tv1Lilic 2 IT2 iiak to 5) Make/Model: Fkl----- 16LN-7 -Li ni, P.R <br />State Decal #: 6) Color: R LIA_E_ <br />VEHICLE OWNER INFORMATION <br />Name: <br />Address of Owner 2_ 1-1-, S. b- i--- 1 e- Qv ‘ ,o, i<1 Z7C9 e'l iq • C)S- _7 --1-- , <br />Street Address City <br />i The mobile food facility shall operate out of a commissary and shall report to the commissary at least once <br />operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary <br />discontinued, the pemitMolder must notify this office to make the necessary changes. Failure to notify <br />office may result in permit revocation and penalties. ._— <br />.___ <br /> <br />' -/15- /t /2 <br />each . <br />is <br />this <br />Signature of Veficle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: _ ex C.40“\-12-cCA 0•\ C-Oc 90M3C \On <br />Owner Name: C---1 . R. C _W, 9" i\-c(\g„-i--'c 3 c. .v <br />Site Address: 2°1 00 L 1-\10,.ca-Noc\wn\...) (,)--koc..kryn CA q5 20 c-) <br />Street Address --, City <br />I Phone: (2CC\ ) tp‘ (.0LA- i, 510 <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 />N Liquid & solid waste disposal 115 1 Utensil washing sink EStore frozen food n Vehicle wash facilities (2 or 3 compartments) <br />n Preparation of food N Hot & cold water for cleaning C4 Toilet & hand washing Store refrigerated food <br />— <br />Store dry food/supplies Provide potable water ril Overnight parking Ki Adequate electrical outlets <br />(___ <br />• VINO- <br />/ <br />Signature of Commiss.ry Owner/Ope ator 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 RENS Date <br />EHD 16-017 5 of 6 MFPU APPLICATION <br />711812008