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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): <br /> Address for Vehicle: -'yo S n /ReoR r UJ' Toti S a0 <br /> Street Address City <br /> 1) License Plate#: #Sud I pen p 4) Year: <br /> 2) Vehicle Vin #: U�� P3.2 KAIL 3 5 clyy� Make/Model: G ,,-kc- <br /> 3) State Decal #: C( . 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: '�U C\ - K\Q vE 7— <br /> Address of Owner: ! 7;?-7 —T E:LeG2 PH vE 0 C� vti (J5 a`/ <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 /> 1 - / 7 - 17 <br /> Si nature of Vehicle 0 erator Date <br /> COMMISSARY INFORMATION <br /> Business Name:CtN-(,jr A Ifs' ' 7,SE lzi C 7 l f--'P' <br /> Owner Name: TaM 7-k� <br /> Site Address: ,40 S, AtK PUZ-1— t C,�li -n in <br /> ,r <br /> StreetAddresscity <br /> Phone: c2�1) 4v , _C��L-V <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 D40t&cold water for cleaning E'Toilet&hand w 5hiriStone re#rigeFated#eed-- <br /> CAL F5RW <br /> ACATERING <br /> EZ/Store dry food/supplies Provide potable water 0vernight;paf4LnJpPLY 19"A%tP99' <br /> 2440 S.AIRPORT WAY <br /> STOCKTON, CA 95206 <br /> Signature of Commissary Owner/Operator Date )466 9000 <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 /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />