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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): TAM 0 W00 <br />0 <br />Address for Vehicle: IN S A ll r rrim <br />Street Address city <br />1) License Plate #: 3BI 7700 4) Year: 00 0 <br />2) Vehicle Vin #:1FDW BIi LilhALF49 K 5) Make/Model: FbrM <br />3) State Decal #: W% 6) Color: <br />VEHICLE OWNER INFORMATION 2-0 0 9211 <br />Name: <br />CI <br />R11 M <br />Lim <br />Address of Owner. mf m wn n �1fl <br />r <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 />offipp may result in permit revocation and penalties. <br />\ rbe5 1"I <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: or 8' ('Arinfio, <br />Owner Name: IMAM ovirroirto <br />Site Address: U , [All for i m A S <br />roWro r <br />Q Street Address city <br />Phone: (Z��) U I'4s ZS- I cmq) <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 />Utensil washing sink <br />Liquid & solid waste disposal <br />or 3 compartments) 0 Store frozen food 2Vhicle wash facilities <br />Toilet <br />16 reparation of food Hot &cold water for cleaning &hand washing Store refrigerated food <br />S dry food/sup lies ide water 101/overnight Adequate <br />potable parking electrical outlets <br />Si We of Co sa w r r or 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 S of 6 MFPU APPLICATION <br />7/18/2008 <br />