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VERIFICA , ION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />s1/r 393%`.✓F V� 6t�Y- „t 2 <br />`�4°I^ exx rz <br />r✓fiICL, � �` 'i <br />^ff xrJuu%tiH &'. .Lk✓�, d+�iP ' i rt'2 f c, <br />Vehicle Name (DBA): aC 1 S <br />Address for Vehicle: <br />Street Address city <br />1) License Plate#: (e 0'52- 4) Year: 1°►82 <br />2) Vehicle Vin #: -'*I "?32M0CVJ1{ 5) Make/Model: r7I/1 ,_f?5!SGlp <br />3) State Decal #: o24(a% g 07-0 6) Color: UJ(Aj }f— <br />��/=,EF�OLE�C��Il1IN)=IINI3IIA°T� , <br />Name: I l I c 1 tt dA e rl aS ©g t�1 <br />Address of Owner: 02,cl KAP)ejyio)ifor.o1 <br />Street Address iCity <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 />discoi u , the perm't ho er must notify this office to make the necessary changes. Failure to notify this <br />off i m y Gsult i e vocation and penalties. <br />►0 / <br />gnat e of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: <br />Owner Name: '' 1 i <br />Site Address: ° Mw <br />1 e <br />Street Addry�.sp a;i)1 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 />i <br />tensil washing sink <br />Liqui solid waste disposal ore frozen food Vehicle wash facilities <br />(2 <br />Prepay of food &cold for '. To'let <br />of watartmer <br />water cleaning &hand washing Store refrigerated food <br />- ore-dq..fapd/ u pli Ovide potable water Overnight king Adequate <br />r pa electrical outlets <br />Si natu f ommiss. Owner perator 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 />7118/2008 <br />