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VERIFICA. )N OF VEHICLE COMOSSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />CLE INFORMATION <br />Vehicle Name (DBA): (> (l S O <br />Address for Vehicle: 2 Z <br />Street Address city <br />1) License Plate #: -9-C, -1 fp 032_ 4) Year: X182- <br />2) <br />1822) Vehicle Vin #: lqffl?32H0-'350q 5) Make/Model: ('t � <br />3) State Decal #: ] °7-0 6) Color: WW 1� <br />Name: 11 I G. F t I C V1 ( 6 Cks dO 8 <br />Address of Owner: T)r. nan:305e Ct1 <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 />operatin day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br />disco i u ,d, the permit hol er must notify this office to make the necessary changes. Failure to notify this <br />offi m y 'gsult i e vocation and penalties. <br />10�1��1 $ <br />Si nat re of Vehicle Operator _ Date <br />COMMISSARY INFORMATION <br />Business Name: � Gc <br />Owner Name: <br />Site Address: er`, anus <br />street Addres9,.7{471 city <br />Phone: <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 />Liqui solid waste disposal tensil washing sink �/ <br />q p tore frozen food Vehicle wash facilities <br />(2 or 3 co artments) <br />Prepare • of food of & cold water for cleaning • Toilet &hand washing Store refrigerated food <br />ore -d+ .f od/ u pli ovide potable water Overnight parking, Adequate electrical outlets <br />ir <br />r p <br />/ (? <br />Si nat f ommissa Owner Aerator 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 />EHD 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008 <br />