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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />V '14i6LE INFooMA-riow <br />Vehicle Name (DBA): L, (\J) ip (\ <br />Address for Vehicle: tp, z 0 6 , ,),(:\ c y ok ave ro_o 51-__ 1 o Or, <br />Street Address City <br />• <br />License Plate #: 7 5 (4 5 S 31 4) Year: 1 6tqs <br />Vehicle Vin #: I D j- P3 2tb2cce 5) Make/Model: CI \\-4 C <br />3 il State Decal #: 6) Color: ,,_) n 1 q <br />volicLE OWNER INFORMATION <br />Name: JO SE o c __ h Oa_ OGVA6o_ <br />Address of Owner: 1 5 5' s , 5ctoranN,e_rvi-c, '; -1- 1 oc-1; cck <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 />6------,_ ----e> <br />Signature ofVehicle Operator Date <br />'COMMISSARY INFORMATION <br />Business Name: Le, wim inzitee., ..c .5-04ey <br />Owner Name: 6+1,e,„frtoz.,d y dcice/ec.,. <br />Site Address: 60 zo ,--_, S-c1-‘/PIV4C-1-e/ -54— 7 5 z 511 <br />Street Address City <br />Phone: (-2,06 7 1 7._ 6 5 5.-7 <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 /> Utensil washing sink F"ri.c.-ruid & solid waste disposal 3kerfrozen food FP-<icle wash facilities <br />(2 or 3 compartments) <br />I I Preparation of food RIO& cold water for cleaning joilet & hand washing 1 --g.t-o-i:".e refrigerated food <br />1.44;e dry food/supplies U.P1"67de potable water [night parking [l-Kreguate electrical outlets <br />J? <br />Signatu' 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 />Signature of County REHS Date <br />EHD 16-017 <br /> 5 of 6 MFPU APPLICATION <br />7/18/2008