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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICL-Mki.ORIUTAT OI N^�� . sr^ K ' 3 <br /> ._ .. '�� <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate#: . 6 gZ Y2-,S 4) Year: a 6.5 <br /> 2) Vehicle Vin#: Make/Model: Fe leo <br /> 3) State Decal#: 6) Color: t T <br /> .�._-.r.... ._ _..s. .•f -t -.. _- ..♦..res---r- �:�. ..� y „-^--....., _ y <br /> ICUF+OWNER,INFORMATION+� ,�� � , � ' •�' .,+ i r�3 Y �( <br /> Name: <br /> Address of Owner: q2S-To�_�t <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 r n p mit revocation and penalties. <br /> ZE0lZi <br /> Slgn_ature of Vehicle Operator Date <br /> 'COIVIMISSARYsIfVFORMATION <br /> Business Name: <br /> Owner Name: ,SAT/V fn s ' ' <br /> Site Address: 3S-7. r L= . Cp A T4 6V T L—:V v�./ -5- <br /> Street Address city <br /> Phone: (vajj c,U _ %A <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 ❑ Utensil washing sink Store frozen food �❑ Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food ❑ Hot&cold water for cleanin�Toilet&hand washing Store refrigerated food <br /> ❑Store dry food/supplies ❑ Provide potable water Overnight parking Adequate electrical outlets <br /> PICK'N GO ICE CREAM <br /> S' 3 �7 �,1 588 r. CARPENTER RD. <br /> 71, `y"�_ �i� UN,CA 95215 <br /> Signature of Commissa Owner/Operator Date <br /> 71, <br /> HEALTH EPARTMENT� '"a r?tiµ YY '� ,�``s �'Tr �'7=i "_a1 ". - -"'`r;.�. <br /> .��- ..:.^.—.�.^_ i•......jS. .�.N. ."t��Yt -'1..,/= .. .'R!.e t4 <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 />