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VIERIFIC TION OF VEHICLE CONM LSSA RY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: ' <br /> X� ' -rG ,l <br /> street Address City <br /> 7 <br /> 1) License Plate#: — 4) Year: <br /> 2) Vehicle Vin#: 3, Make/Model: <br /> 3) State Decal#: `�' � t5'6 'Color: (9J I -ic <br /> i ( 1 LIL <br /> VEHICLE OWNER NFORMATION <br /> Name: �gnw2i'�1 —�� 1 <br /> r <br /> Je"dress of OtiNner: /C <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 /> Signature of Vehicle Operator Date s <br /> COMMISSARY INFORMATION <br /> ousiness iVame: C6 f i;pryl'N C61-7-160,'—,In 0 __ l <br /> Owner Name: ✓ r J <br /> Site Address: /S. q r; O r f,✓Gi l i JZ" CC <br /> Street Address V / city <br /> Phone: ( Loq) o CC — 20bof <br /> I, t;-.e commissary owner, can and will provide the necessary facilities for tVe i e�'a veTrc( a <br /> commissary as checked below: <br /> ritllF0 CATERING <br /> SUPPLY FOOD AND SERVICE <br /> Liquid&solid waste disposal R Utensil washing sink Stole fr zen food 2440�lAtFgRp?TVg(�cilities-=^ <br /> I (2 or 3 compartments) STO ON, CP.95206 <br /> (?0.9)466 9000 -.•s.� '. <br /> Preparation of food fT Hot&cold water for cleaning 7�. Toilet&h.5;71 wasMing foad <br /> K1 Store dry food/supplies PLProvide potable water Overnight parking Adequate eler Tical outlets <br /> Signature of Commissary Owner/Operator _ Davi _ <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishmen is outside San Joaquin County, the local health jurisdiction r(iust verify <br /> current health permit by signing I-iow C imissary/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 />