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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): 1„.1 .. \jick 6,(ThA,ck , <br />Address for Vehicle: 1,340aije )67/V 'V <br />Street Add res — City <br />License Plate #: 71:7-L70( 7 0 4) Year: /6( 8 <br />Vehicle Vin #: /UTC-1--iorgESow5 5) Make/Model: ji 161 &a State Decal #: 6) Color: <br />VEHICLE OWNER INFORMATION <br />I Name: IAA , <br />Address of Owner: 33,949 )W6 AAPE (961Y#C1-- 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 />Cc C. _ ! .I, . ‘...........k..\ .... \--( <br />Signature o ehi e Operator Date <br />COMMISSARY INFORMATION <br />Business Name: NcK ci. 67 j(c-c.. cpsE-F,G,7 <br />Owner Name: <br /> <br />Site Address: 2 s- F._ p ,--_-• . c/4 co - -- 6 _, / -.7-_-_-,R ‘-), s 7. .. 57...0 c K .7 _,I.,7 ci4 6? s----. .5.^..\ <br />Street Address City <br />Phone: (...- ) q,,k \-,___ f•-1 kci• <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 Liquid & solid waste disposal ----1 Store frozen food Vehicle wash facilities (2 or 3 compartments) <br /> Preparation of food Hot & cold water for cleaning Toilet & hand washi -IN Store refrigerated food <br /> Store dry food/supplies 1 I Provide potable water 5-1 Overnight parking Adequate electrical outlets <br />_ .,;4_,,,„_, _c,4,--- , c--,-;,-,„ - ,' (4 — ei ___ .,,XNE__cN GO ICECRH:g. <br />Signature of Commisfary Owner/Operator Date STOCICTON, CA 95215 <br />HEALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin <br />current health permit by signing below. Commissary/food <br />County. <br />County, the local health jurisdiction must verify <br />establishment is in <br />Signature of County REHS Date <br />EHD 16-017 <br />7/18/2008 <br />5 of 6 MFPU APPLICATION