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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): Le- C6N44t%r, <br /> Address for Vehicle: 0-tyytj 5, \r T- \�'J' S lotkvi.� <br /> Street Address city <br /> 1) License Plate#: 1>1S'A I-I a 4) Year: 19-t% <br /> 2) Vehicle Vin#: I@tctl05W 1311-53 5) Make/Model: Qr%!Ly4 i L,3o <br /> 3) State Decal* Cit 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: Mcg, O.., Zr <br /> Address of Owner: j-ooI GAccf;«fid S}v kAon <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 /> e <br /> 1 <br /> Si nature*ofehic1e)J"L6jDate <br /> COMMISSARY IN RMATION <br /> Business Name: L e Q Arty <br /> Owner Name: A a', JLh <br /> Site Address: 31940 5 ',r fort Wlv, S <br /> street Address city <br /> Phone: ('o`) ) (o%4 -d <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 ® Hot&cold water for cleaning ❑Toilet&hand washing © Store refrigerated food <br /> Store dry food/supplies ® Provide potable water ❑Overnight parking ❑Adequate electrical outlets <br /> �^ 1TJOZ,In, <br /> Signature of Comm iss Owe perator Date <br /> HEALTH DEPARTM NT <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 0f 6 MFPU APPLICATION <br /> 7/18/2008 <br />