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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> �'� ^ °i x � <br /> VEHICLE �N1=0RMATIQN �' <br /> .f �..w• iR"SC's,,ti u.wtz..,,. �"} its t e' <br /> Vehicle Name (DBA): <br /> Address for Vehicle: ( _ 3 <br /> Street Address City <br /> 1) License Plate#: !21 LJ 1 '2 / -S Q 4) Year: j � ? � <br /> 2 Vehicle Vin #: �� <br /> 21�� k �3�Z�if�l��) Make/Model: 0O,f� <br /> 3) State Decal #: 6) Color:W. <br /> VEHICLE OINNER,'..NFORNIATION Y °+ <br /> . <br /> � ' <br /> Name: <br /> Address of Owner: <br /> Street Address city <br /> The riibbile 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 /> x;f x aP t�,{i. t r <br /> COIVIml SARI(IWFQRMATION C ` per' a r' ;5 ' "' R <br /> Business Name: C- C C�C C' C0 m <br /> Owner Name: S'A— 1Y7 /"�C, 1./ <br /> Site Address: -7 o C),4� ►o n/ c�a aS`�\1� <br /> Street Address city <br /> Phone: Cf L1?"-, /.7 k q <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 <br /> (2 or 3 compartments) Store frozen food Vehicle wash facilities <br /> ❑ Preparation of food ---4:] Hot&cold water for cleaning 'Toilet&hand washing Store refrigerated food <br /> El Store dry food/supplies ❑ Provide potable water ---� Overnight parking -�Adequate electrical outlets <br /> S _ �PIM N GO ICE CREAM <br /> �'3 <br /> 8 E. CARPEN'T'ER RD. <br /> Signature of Com missCry Owner/Operator Date ST ( II�TQiV,CA 95215 <br /> �crLhJs3.t '- 1'.Yfi rt tlifA <br /> Wa�X <br /> H.EA -TH 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 RE HS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />