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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay.approval. <br /> ��>'•�¢�- <br /> -+-��'��!. x� ..e1:-r. -.r., 'dr.'r`.�� K a.•,: Ga•._a. rr_.. •a �;.�;_;,=�t_iy-'5.'.k;:-. <br /> Vehicle Name(DBA): <br /> Address for Vehicle:. <br /> street Address city <br /> 1) License Plate#: �j (V-0-'Y3 ~tom 4) Year. 8� <br /> 2) Vehicle Vin#: i G C,c,h,s 0. G �-7 5) Make/Model: C <br /> 3) State Decal-#: 6) Color: -� P <br /> �. Y Lair ti�z'.irvra=.:a....CrSa:. ,_, �'" �Yr`� f� �'t��3_ '' x•'�'2� �.'-:,� _-,�;y�-�,t�,��- <br /> :-�- _� �_.,�_ _ �D!tE,#�''1 _ -'� ._.-.:.� _ �•-�:`���� � .-�"-� t ;*�}s 7�,-=n'�.w-iS��f/�'�'��c'��_.�r3'�-;2rx�-'—:.. <br /> Name: 1` <br /> Address of Owner: _J <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 81;1429'). 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 avocation and penalties, <br /> Si nature-of Vehicle Operator Date <br /> � � a <br /> Business Name: Pj _CkD <br /> Owner Name: — cr-7 ff ' <br /> Site Address: �Ssr G-C, C, fV 'TL S?o C f< Ta CyfCa °< <br /> street Address city <br /> Phone:(meq) °► - <br /> 1,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 ❑ Utensil washing sink �Sfiore frozen food � Vehicle wash fac�Gties <br /> (2 or 3 eomparlmenft) <br /> ❑Preparation of food Hot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> ❑Store dry foodisuppries ElProvide potable water Overnight parking Ade uate electrical outlets <br /> C� <br /> PI 'N f�0 ICE CREAM <br /> 3533 C CARPENTER RD. <br /> -$TOE;IiTOiV,CA 95 95215 <br /> Signature of ComiffissaOwner/Operator Date <br /> x, .�„e, - -'"- �-��.{�;,;"�'-t��xr y�;'�:S"`,�"''S,�.�. ^�„z,•- W;';a -'.-t,.r -r b,�._r,f. �.�ria <br /> If the commissary/food establishment is outside San Joaquin County,the local healthjurisdiction must verily <br /> current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County RE HS Date <br /> EHD 16-017 Sof 6 - MFPU APPLICATION <br /> 7/18/2008 <br /> A <br />