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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 (D BA): T\--ya C—Kee.,_.. `.--c,--0L---,4-N ±(\c• . <br />-t-. Address for Vehicle: (2:" Q L) Q Cc'et ‘(\iNati\-\--CD <br />L\ C Street Address -W ---N <br />License Plate #:(33(..o c--1 4-4 Nk 4) Year: 2.0k <br />Vehicle Vin #: .\,,v-;.-ze ick us- i cs(v2q) Make/Model: <br />State Decal #: OF\ 6) Color: <br />VEHICLE OWNER INFORMATI N r ....., .., ,-, <br />Name: c..:),,(-0,.(N-k0 liV \ A \ _e--io S ( i- ,) GI - Ci-41 <br />Address of Owner: 27(o yu .,,..,2:\ Assexv\o,t\ k vk <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, t -p - it holder must notify this office to make the necessary hanges. Failure to notify this <br />office may r -: . t. 'I? mit revocation and penalties. i <br />j-° 1 Cf <br />Ail <br />/ /Allk •... ..- Signa r- ." : icl-Sgs,r— \ Da e <br />Cq, MISS i 'fib - ATION <br />Business Name: zefri kyw 5 se*- y A Z .-i- <br />Owner Name: pleikoeit ro 0 cylot_ <br />Site Address: 6 0 5 5ec-47.4441,e 449 15 2.,;,0 <br />Street Address City <br />Phone: (201) 019 q g-33 5i <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 />nsil sink F,T,"----' <br /> Liquid & solid waste disposal Ute washing I-0<tore frozen food ip-- Vehicle wash facilities <br />(2 or 3 compartments) <br /> Preparation of food I Vrot & cold water for cleaning1-0<let & hand washing WS'tore refrigerated food <br />Rcore dry food/supplies [--Cvide potable water rXvernight parking VA/dequate electrical outlets <br />Signature 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 RENS Date <br />END 16-017 <br /> 5 of 6 MFPU APPLICATION <br />7/18/2008