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3Z4k-La <br />VERIFICA IION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): -:._-Th LT--..(4,_-, <br />Address for Vehicle: -9-1-7:11- -_ .\ u:-.3 \- <br />License Plate <br />Vehicle Vin <br />State Decal <br />Street Address City <br />#: 4) Year: <br />#: '-\3\ 3 -c) Make/Model: c--3r,c,-2-,-,e <br />'F #: -D og. --t-00 6) Color:\t-,cke- ( <br />VEHICLE OWNER INFORMATION <br />Name:--(-2-0\6‘(-- P7-..ii--s-V‘eity-Nc t,---N ( <br />Address of Owner: c---yLA u3 \(_--Nr,,,itLD \_.1,\ , ‘ry-\.\--, .4.(L) 0\c\s-2.,c-A \ <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 />discontirued, 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 />o— \rr"-4::._.--0-0---4-j\ e___\ _ --7....-) <br />Signature of Vehicle Opeiator Date <br />COMMISSARY INFORMATION <br />Business Name: <br />Owner Name: ea.2_aL_J `V--, --\----(21-\ <br />..— Site Address: --7-c-a Cv-Nke_f--- pr ‘----...- C7)\-ce- -,--.7-„.--_,-) <br />Street Addres _.) City <br />Phone: ().(5A)1C-25-7. - <br />I, the commissary <br />commissary as checked <br />juid & solid waste F< <br />Ti Preparation of food <br />Store dry food/suppli <br />owner, <br />s <br />disposal <br />can and will provide the necessary facilities for the above mentioned vehicle at my <br />below: <br />ensil Ti Lit wash ing sink <br />(2 or 3 compartments) Ti Store frozen food Vehicle wash facilities <br />K1-1113t & cold water for cleaning Et-T-P-ilet & hand washing LII Store refrigerated food <br />I rOvide potable water vernight parking li----ATequate electrical outlets <br />'\• .3 <br />Signature of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <br />If the commissary/food establishment <br />current health permit by <br />County. <br />is outside San Joaquin County, the local health jurisdiction must verify <br />signing below. Commissary/food establishment is in <br />Signature of County REHS Date <br />END 16-017 <br /> <br />5 of 6 <br />MFPU APPLICATION <br />7/18/2008