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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />. <br />Vehicle Name (DBA): ,/ (1,1 0-/E--/q EL 1 J/', i ll <br />Address for Vehicle: <br />Street Address City <br />License Plate #: S fi 6 i7 0 4) Year: i ec ?. 7 <br />Vehicle Vin #: 5) Make/Model: til ti <br />State Decal #: 6) Color: bj(-{(1--C-2 <br />VEHICLE OWNER INFORMATION <br />Name: R R (if L E,'? ( 2_ ,1 <br />Address of Owner: ,c- //// _S /4//:-/// (j/ay ,f,. _5 -7 c") 2 <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 114296 & 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 />7// b 5— <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: tuiirt ft) C, 'A16' (XUcK CE_n_i'l -& <br />Owner Name: j fq L 04- 0 rj()_ —TT K-ft D C <br />Site Address: ( 7(7 5' Ll /LI i c) it) ___.s 'i . 5' c c c_rrr 111, C a <br />/ <br />2c) ?Street Address City <br />Phone: ( ) c7, ? F.- ' 5 e,(/ <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 />EKItensil washing sink Wiquid & solid waste disposal rqrgtore frozen food HVehicle wash facilities <br />(2 or 3 compartments) <br />FrPreparation of food --"Hot & cold water for cleaning 1-ilet & hand washing Store refrigerated food <br />Store food/supplies 77rProvide potable water 7 C--;:terni ht parking Fq‘iequate 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 REHS Date <br />END 16-017 <br /> 5 of 6 <br /> MFPU APPLICATION <br />7/18/2008