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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 I / L OS (i <br />Address for Vehicle: pt 0 , A ox /Is' 7 6 5 -r-6 (en iki LH 9_67,2 / -6 : Street Address City <br />; <br />License Plate #: <br />i 4 <br /> <br />D <br />j 4 ( <br /> 7(7j <br />4) Year: I <br />Vehicle Vin #: 5) Make/Model: 6 ol 4- <br />State Decal #: 6) Color: tij H 11-6' <br />VEHICLE OWNER INFORMATION <br />Name: ,Tb.,56 0 /-ifv*,' I 0 67 iil_ I; /ill! c i-Te h D -L-z. <br />Address of Owner: 1-1., 0 , Bc.i-x_i-t% 7 6 5-11)04_11, i\ cAA- ck 5-.2_ I 0 <br />Street Address r 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 />1 4' ..,.21..„-a i'--1:, )i.,---,..--,-..._. i /2 i / ci <br />SiO/ature of /ehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name:,°k NI ‘ c iii r /I rc5 IZ I t6 G U C- t(- C- E NIT& A--- —....,-- , <br />Owner Name: 11- ksfE vyk)D i ?RN) _ <br />Site Address: 1 7 1 7 S. ut ivi 0 Ili 5T ,57-06-..K-rt, id cif,-IA,' <br />2 t Street Address City <br />Phone: ( ) Ci) 5 - 5 11 I C; <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 />, <br />1--Vehicle wash facilities FKiquid & solid waste disposal IZUtensil washing sink ,--, <br />1 t-r Store frozen food (2 or 3 compartments) <br />, <br />[1•Kreparation of food RHot & cold water for cleaning Toilet & hand washing 1-/Store refrigerated food <br />—:/ore dr food/supplies al/Provide potabte water R6vernight parking PKdequate electrical outlets , <br />/i 9 <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 />EHD 16-017 <br /> 5 of 6 <br /> MFPU APPLICATION