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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 Nam7(713 .( . <br />Address for Vehicle: 9 = a-I-cola,- v•evd?7"--,) 6ew ?5-,)z)c-- eIv <br />Street Address oily <br />License Plate #: 5—Levg 79,9 4) Year: /e.0 <br />Vehicle Vin #: /G 0 ii 10,90:Z MIC G 3 5-.0 3,5) Make/Model: e 44 <br />State Decal #: c1- iiq- 2"/ 6) Color: fia-JZZt2 <br />VEHICLE OWNER INFORMATION <br />Name: t" <br />Address of Owner: (:od- // <br />7 ___, v , ., <br />hi/ 6-4,), -iy, , ai4- 95-3o7 <br />City Street Address y <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 /> <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 />i.,/)1 C 11 1C73'Y -c_fc- (.4--7/ / <br />Signature of Vehi le Operator Date <br />COMMISSARY INFORMATICM <br />Business Name: <br />Owner Name: jb i 1 el/L.4 / / -- 4 ,. <br />Site Address: z,(),, e: 1 ) 60 90 <br />Street Address /— ; Cll <br />Phone:A/Y) ,z/I pq _ L--7z) <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 />a <br />Y1 Liquid & solid waste disposal N Utensil washing sink Store frozen food Yi Vehicle wash facilities <br />(2 or 3 compartments) <br /> Preparation of food [g Hot & cold water for cleaning 'S Toilet & hand washing n Store refrigerated food <br /> t6è dry food/supplies Provide potable water .,. NI Overnight parking ig Adequate electrical outlets <br />, <br />- <br />Signature of Commissary Owner/Opd o 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 <br /> MFPU APPLICATION <br />7/18/2008