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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): S T FrC �r/Ts ,AI <br /> Address for Vehicle: 0 /V CC �' �q <br /> Street Address City <br /> 1) License Plate#: qE r—,3Z 4) Year: 2003 <br /> 2) Vehicle Vin M 5) Make/Model: �f L Al h)e k <br /> 3) State Decal#: 6) Color: I'fiC= <br /> VEHICLE OWNER INFORMATION <br /> Name: 54LLQUOA �Z <br /> Address of Owner. /,5- <br /> 6'3-3 c5 . <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 /> ofFce ay result' permit r cation and penalties. <br /> S !r <br /> Si nature of a icle O erator Date <br /> COMMISSARY INFORMATION <br /> Business Name: yo D4, U G 'AurLx <br /> Owner Name: ,1/ p <br /> Site Address: / 70 L(/V b/i) S'r_ 0G c '77� C [-9Z6 <br /> Street Address City <br /> Phone:�o <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 [2,"`cnsil washing sinktore frozen food hide wash facilities <br /> ((22 or 3 compartments) <br /> Preparation of food clot&cold water for cleaning oilet&hand washing store refrigerated food <br /> Q Store dry food/supplies EDorovide potable water Overnight parking Adequate electrical outlets <br /> Sin ure of Co missa 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 /> EHO 16-017 5 of 6 MFPU APPLICATION <br />