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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): <br /> Address for Vehicle: qly, 46'S jUL , Z ' 96-33(L) <br /> Street Address city <br /> 1) License Plate#: `���j.i� S ( 4) Year: CD cy <br /> 2) Vehicle Vin#: 5) Make/Model: C(ycV EX/OA-6--5 . <br /> 3) State Decal #: 6) Color: L 64 <br /> VEHICLE OWNER INFORMATION <br /> Name: 5M kti fi Elt%' _ <br /> Address of Owner: /[ L, �((f1-?0)0 C1 �32(C) <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 in permit revocation and penalties. / <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: Lt IVlc Ct�(.� j NJ(- 2- LACK <br /> Owner Name: 11211 C) ( A 4 6 <br /> Site Address: / 7 7 ,j , Q N I d f� -J-1- <br /> Street <br /> J r; .Street Address city <br /> Phone:T- �� - - `{ <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 /> Liquid&solid waste disposal u `utensil washing sink [-�.�tore frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> 13Preparation of food Hot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> Mood/supplies O'Provide potable water 9�verni ht parking equate electrical outlets <br /> Signature of CommissaryOwner/Operator 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 RENS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/1812008 <br />