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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION , . 14 . <br />Vehicle Name (DBA): 779c6,5 t-i, (.-6--RO <br />Address for Vehicle: / 9// H(,iJ , /,z, y-,5L61---6A1) c4 7,5-‘ r'( <br />Street Address City <br />License Plate #: 4 ( <br />, <br />ril N <br />, , <br />AY 75- 4) Year: ,2 0 /3 <br />Vehicle Vin #: 5) Make/Model: u57' 14 <br />State Decal #: 6) Color: 05 ( . (E: <br />VEHICLE OWNER INFORMATION <br />Name: SeAti-h 0-\ / i \) MA KA v I Le_ ii- <br />Address of Owner: / 5/9 i /-611 / j,2, ,T-,5 f 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 />/ <br /> <br />Sign re of VeTfe Operator Date <br />COMMISSARY INFORMATION <br />Business Name: upifotti cfr7--6 /4/6 ,--ri-Nk. c 6 M re-A- <br />Owner Name: NJUL----//4 / 0 / / fi fi el b <br />Site Address: i 7 / 7 s, (A, AI( 0 (k. 5 -1-7 5Tb 6.___.-1-66.1 ch ?6--„ 0 <br />0 9 2 Street Address / City <br />Phone:( <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 />washing sink Liquid & solid waste disposal reUtensil R‹ore frozen food rehicle wash facilities (2 or 3 compartments) <br />FP 14reparation of food Fl4ot & cold water for cleaning 1-17bilet & hand washing FV(Store refrigerated food <br />74tore dry food/supplies Fli<oyide potable water R/Oyernight parking Mi<dequate electrical outlets <br />, ___---i <br />r <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 />EHD 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008