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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> �/EHIGI:E NjF�yQve <br /> L..n. ...yF.� ,.r. Af Y. N.a`V wi .+:b�.�.hh} n x.q✓�R aF.��M*..VF.+K;` <br /> Vehicle Name (DBA): M TOO I <br /> Address for Vehicle: 170 S caS <br /> Street Address city <br /> 1) License Plate#: '3004 IT2, r 4) Year: N014 <br /> 2) Vehicle Vin#: M ? Z.Kq 39%14%ake/Model: G <br /> 3) State Decal#: (/f 6) Color: <br /> V � ""`. ���' a,EHInCIEINE, INFORMAROFN � �' � k ' <br /> Name: 5- <br /> Address of Owner: f . M(AMP Oft <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 <br /> office may result' pe mit revocation and penalties. W �� <br /> An w�i <br /> Sin ure of ehlcle 6perator Date <br /> 0 MIW0—,'INFORMATION . � f <br /> ¢. <br /> Business Name: GAIltoy lot (AWN UA�Mffl <br /> Owner Name: ROM In Va la <br /> Site Address: -I-"10 <br /> Street Addres City <br /> Phone: (an iui in i /m 0-1 l- 1141 <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 /> iourp, <br /> d&solid waste disposal Ut nsil washing sink ❑ Store frozen food Vehicle wash facilities <br /> ( or 3 compartments) <br /> El aration of food Hot&cold water for cleaning Toilet&hand washing ❑ St e refrigerated food <br /> dry food/s lies rovide potable water Overnight parking Adequate electrical outlets <br /> gl <br /> Agr <br /> tyre of T&mw —ary Owner/O erator Date <br /> + 111�..; 6' lir({ a ��� '$'"F;4.- Y•a <br /> HEAT DEP' RT E <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 iftftw <br />