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O <br /> <44:co— iE.r3w-s SSARV DF VEHICLE COMMISSARY <br /> CONNIE FERNANDEZ 3ested. An incomplete application may delay approval. <br /> Office Manager <br /> '"AINIOW cea • 209-464-4570 ante • 209-463-2102 fax <br /> connie@lacomerclalcorp.com•wwwiacomercialoorp.com <br /> 2900 E.Harding Wag Stockton,California 95205 address <br /> P.O.Box 379,Stockton,California 95201 mail <br /> -- —AdlLfre55-T(Tr4ERICre: _ ( "S149 <br /> Street Address V <br /> urvy <br /> 1) License Plate#: �jQ{(s 4) Year: e)/o'P- <br /> 2) Vehicle Vin#: y/ /L�/%Z/o71 ✓SD��Is$ 5) Make/Model: I <br /> 3) State Decal#: C 6) Color: <br /> VEHICLE OWNER INFORMATION v <br /> Name: y�rt <br /> Address of Owner: ad s <br /> Street Address U 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 <br /> in permit revocation and penalties. <br /> of Vehicle Oper r Date <br /> COMMISSARY INFORMA ON <br /> IV <br /> Business Name: r'4a 14 <br /> Owner Name: , <br /> V <br /> Site Address: Ar2le9zi E. S <br /> Street Addrcfss city <br /> Phone: 1n) - <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 LAI Utensil washing sink ❑ Store frozen foodVehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food Hot&cold water for cleaning UToilet&hand washing ❑ Store refrigerated food <br /> ❑ ore lc�r food/supplies Provide potable water El overnight parking El Adequate electrical outlets <br /> ' 3-cps--/ <br /> Signature of Commis ary Owner/Operat r 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 5 of 6 MFPU APPLICATION <br /> 7/1812008 <br />