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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> s-spn.--.•tr-^i.eP`e'un-orc;rlx+-.cr..l +n.....•pemy r, +y.r1„ e.,..- iy: _r_..r.v..t: �_. <br /> 1r ` y'4'y;',-:,Ygty'` v t'r '-•4.. __ _ _�._. ...� .ue�._f.�...s�d�Jlui'n.�......._ia...�.....Liti�iL&I.z.�:i'i_4..3c_ #,"rif..� 1:tW,.YA?.P��42'R45.11Fy'i.°.3K.N�ine1: <br /> Vehicle Name (DBA): Ct Z o-Vi <br /> Address for Vehicle: IOL 5 S C(cC i t a n r i 0, +« c <br /> Street Address city <br /> 1) . License Plate* u En t-( S 4) Year: 2c o <br /> 2) Vehicle Vin#: U 7IZ I to 1 nu/_�innn J1 ,Make/Model: A dK F 1t <br /> T- <br /> 3) State Decal#: 6) Color: <br /> �'n"ye J'-"sce4y-v+cYt'Y.ra•!rx..c+tnaa.stx�r. 'TM I '16 R TY'SI yN"f�*. 1 T:�. -•Yn •• 'l:P:'.. "'1 YY T�v r'X": N`�TT� '!''jY' <br /> Name: <br /> Address of Owner: <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 <br /> COMMISSARYI_NFOL2MATION" J w`"+ka ? at s "R` y �r + `: : YjF*i7 reFtL��d <br /> 0. __ _ x.��.... ._�:a.a.a:.n�,.e3amnt� �s�i'�.J Y_�n:ri.a�+�,�F•ui•', ��1..._,.._. t..'E...ffiffl <br /> Business Name: az- <br /> Owner Name: <br /> Site Address: Lf ZtZ2' r-- f v ,Lj G <br /> Street Address city <br /> Phone: (J„()!9 <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> z <br /> Liquid&solid waste disposal ® Utensil washing sink Store frozen f o��' ALtY ,,O IA ( �TSRR N E <br /> • (2 or 3 compartments) _SUPPLY I-UU IVU t <br /> Q Preparation of food Hot&cold water for cleaning ®Toilet&hand WNW I <br /> ✓f• (209)466 9000 ' <br /> ElStore dry food/supplies Provide potable water �.Ovemight par n-----a76d Uate electricEirb <br /> Signa ure of Commiss Owner/Operator Date <br /> i'. _.�.T r �;�s�,tP."n�ti�v+C"s.,res ^:/+, b ri mar: i p -:t, �. .;x.r.;r • -��:�< <br /> %. el <br /> If <br /> 714 r't'J 1 SJ",' a- Sr2' •" , y�,,u�..� 7 ','Y�t,-;i=�''� <br /> LF(I_EAL;THjDEPA_RTMENTc , v2>�li:t^,���''��fi�i.��Y,{i�� :�{5"i�..s''.,;..�s�..'�^�,,F._s�i`p'.A���Aawly�,Ucfy��$�trj ar'.eCr:7i• %'.zrM�3.ti"4:i. <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 />