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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />CL <br />VEHIE"INFORMATION, ` <br />Vehicle Name (DBA): <br />LFS <br />Address for Vehicle: i7 l S A �, (f <br />Street Address city <br />1) License Plate #: 419 A -S P �. 4) Year: I � q 2- <br />2) Vehicle Vin #: %�,}C� N 77t I URj5) Make/Model: CAE-y- <br />AEy3) <br />3)State Decal #: 6) Color: <br />A EHfCLE Q.MNER-`IN//hhFORMATION <br />Name: Ila W0 <br />Address of Owner: i i Q w N r sto (1k 10 <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 i 0 revocation and penalties. <br />Signature o Vehigle Operator Date <br />rOMMISSARY INFORMATIOpp N _ <br />Business Name: rn i <br />S <br />Owner Name: JAIVA00 K P t <br />Site Address: <br />_Sheet Address city <br />Phone: (Ld ) 4 <br />I, the ommissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />co issary as checked below: <br />i <br />uid & solid waste disposal Ut nsil washing sink ❑ or 3 compartments) Store frozen food 21"Vehicie wash facilities <br />eparation of food of &cold water for cleaning [fo t &hand washing ❑ ore refrigerated food <br />dry food/su ties P de potable water Overnight parking Adequate electrical outlets <br />ature of ssary Owner/Operator Date <br />HEALTH DEPARTM <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 <br />