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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />' fa Th,‘Tki0: <br />, <br />Vehicle Name (DBA): Lc k @C(---\"01 CI-K-0 MP, <br />Address for Vehicle: \Ot'60 `‘' 'kS ,) (1\4 <br />Street Address City <br />License Plate #: CP\ B -CI) 3C3l3...::\ 1 4) Year: <br />Vehicle Vin #: 4- (---1 C H-F -32 3 7 5) Make/Model: CINt\jf <br />7 4n- State Decal #: 6) Color: Q- \ \Ie -N.' \ <br />_ ,..latawrisite <br />Name: 11)01/4\rkoi, .\) C(:?(,V. <br />Address of Owner: ICJ -214_ ,Ki Au:\ co ft-i._,, c v.,A ,i-, <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 />discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office may result in permit revocation and penalties. <br />9-4 lia CA -926 IL L5t.i tq Signature of Vehicle Operator Date <br />, , <br />Business Name: 00011%0Ak X('\k 1\271/4--eCCA <br />Owner Name: Ac\e-Tkm.c 0 Ocv\ ock <br />Site Address: Is 21) _ efockea-vv\p"#0 sl-- Z-06 \ <br />Street Address City <br />Phone: (20 ) 2 2..I -633,4 <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 />51 Utensil washing sink I' Liquid & solid waste disposal U III Store frozen food g Vehicle wash facilities (2 or 3 compartments) <br /> Preparation of food VI Hot & cold water for cleaning 1SZI Toilet & hand washing U Store refrigerated food <br />IN Store dry food/supplies n Provide potable water 54 Overnight parking K. Adequate electrical outlets <br />12 Signature of Commissa Owner/Operator Date <br />v : , ,..,, <br />----- <br />- <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 />,. <br />Signature of County REHS Date <br />EHD 16-017 <br />711812008 <br />5 of MFPU APPLICATION