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Date <br />VERIIRCAIDOW OF VEHCLE COMIESSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />I VEHICLE DNIFORIIIIATIONI-_,,-, <br />Name Vehicle (DBA):pale,-- <br />, Address for Vehicle: ,..9--/zo e s ki-tio) 0,-1, (Wielk.6--_„ <br />/) <br />(- <br />(9P <br />Street Addms. 2 City <br />A—ev,z d A"' — ' . i a 4) Year: e,;Z 0/5 1) License Plate #: /. _ , , , — i 2) Vehicle Vin #: /W cM/4-475:577--cA,2 9 5) Make/Model: /4 /) P /-/- <br />3) State Decal 6: (.° Al- 12-0 6) Color: <br />VEHICLE OUTER ONIFORMTIOM /- ,-, <br />Name.. <br /> <br />ritez__ )3,4,0_6.3,t, <br />Address of Owner: / 5V ev? , <br />, Stree Address <br />i <br />7 <br />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 114205 :1, 114207). If the use of the c—issa-ry is <br />discontinued, the permit-holder must notify this office to make the necessary changes. Failure to notify this <br />office may rase ijvpe , iv revocation and penalties. <br />Signature-tf Vehicle Operator Date <br />CORfiittiISSARYWFORIVIATIOIT: <br />Business Name: <br />`a, " (2,CN's p " Pvc .(WhA Owner Name: <br />Site Address: 261 00 L. 1--.10;.(-6,-\ <br />Street Address <br />Phone: (20-1) ((ILA' 6 -10 <br />the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />)( Liquid & solid waste disposal 1-/-1 Utensil washing sink <br />(2 or 3 compartments) • Ell Store frozen food g Vehicle wash facilities <br />. I <br />Hot & cold water for cleaning Toilet & hand washing 0 Store refrigerated food Preparation of food <br />I <br />Provide potab e water N Overnight parking KI Adequate electrical outlets <br />1 <br />_) /T7 <br />Signature of Commiss ry Owner/Opera <br />/ HEALTH DEPARTillinfr <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />i current health permit by signing below. Commissarylfood establishment is in <br />County. <br />Signature of County REHS <br /> <br />Date <br />END 16-017 <br />7/1812008 <br />5 of 6 MFPU APPLICATION <br />dpe) <br />f-c- <br />âkockcrCA C15 21) I:71 <br />City ' <br />n Store food/supplies <br />241-(„2