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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 for Vehicle: a2 11 6 )iii i hi r A-,Q2-- S1iC le 12-1,-- <br />Street Address City <br />License Plate #: ,-1 12-e- 1 Sil 4) Year: 20113 <br />Vehicle Vin #: l-Mci PA EA '° —3Vi3b0 5) Make/Model: fii(:C,11 / erCicSed <br />State Decal #: 6) Color: <br />VEHICLE OWNER INFORMATION <br />Name: MO, j6_, Oet(i'yia, <br />Address of Owner: '3. 1 i C. pi ote v Ayse ''Z--rbc ie -tbn <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 />Signatur f Vehicle Operator Date <br />COMMISSARY INFORMATION ale— a r-e.- n/27 - Ci Cp15Sqly <br />Business Name: ..-ii, w ate d <br />Owner Name: /--/c0--d ek,i, <br />Site Address: 27/6 F 771,,,/,/e ,,-- S-peti--0-7 ? 5 7,2S-5 — <br />I Street Address City <br />Phone: (20 r fl„ — 7.-. 70 <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 />inkhi il / washing sink & solid waste disposal Utensil 1 1 Store frozen food Vehicle wash facilities <br />., (2 or 3 compartments) <br /> Preparation of food ot & cold water for cleaning Toilet & hand washing Store refrigerated food <br /><*t <br /> Store dry food/supplies ovible potable water , Overnight parking [ 1 Adequate electrical outlets <br />, -13 —/7 <br />Signature of Commissary Owner/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 REHS Date <br />END 16-017 <br /> 5 of 6 <br /> MFPU APPLICATION <br />7/18/2008