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VERIFICATION OF VEHICLE COMMMSSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> V=HICLE INFORMATION <br /> .ucle Name (DBA): 1/ - __ 1 4- G - <br /> Address for Vehicle: 4C `'l ' - <br /> Street Address City <br /> 1) License Plate#: 4) Year: <br /> 2 Vehicle Vin#: ! ' -Make/Model: <br /> 3) State Decal #: " l5_b�`Color: l t� <br /> tI <br /> VEHICLE OWNER INFORMATION <br /> a <br /> Address of ner: /09 / 13eO4C h Cy 1-1 1,., 01- Jr�C /c l`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 (CaiCode sections 11114295 & 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 <br /> COMMISSARY INFORMATIONI <br /> Dusi�less Name: L G l r 9(+�, C&!%'(d�—i to 5 /0. <br /> Owner Name: M r'lI u On — -- <br /> 5 <br /> Site Address: � � j �;r. �r ' � r <br /> Street Address ° / city <br /> Phone: ( ^Or) q 0 C D _✓ -- — --� <br /> I, the commissary owner, can and will prcvide the necessary facilities for t W,Ljp#ati a ve Ic atm <br /> comm,63ary as checked below: , � '-°��j CATE Ny'y- <br /> SUPPLY I-OOD AND SERVICE <br /> �] Utensil washy g sink 2440yf� �h?� jcilitie:= <br /> Liquid&solid Waste disposal Store frzen food(2 or 3 cu npa tments) STO ON, CA 95206 <br /> ( )466 9000 <br /> Preparation c f food rJ Hct 3 cold wat r for clear' ] Toilet&hana was i g "st:rne�eldg�ra'�E'-iae <br /> Sto,e dry food/supplies {Zlrovide potabie water Overnight parking Adequate electrical out <br /> Signature of Go�ary Ownei/Operatoi Date <br /> IiEALTH DEPARTMENT I <br /> If the commissary/food establishment is outsic,a San Joaquin County,the local heaith jurisdiction must verify <br /> ".urreot heai`h permit by signing below. Comn 'ssarv; rjoc' establi,:lzment is in — <br /> r ;ounty. III <br /> M <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/181?_008 <br />