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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): Ct <br /> Address for Vehicle: < ( = 3 <br /> Street Address / city <br /> 1) License Plate#: �Lll 1 2 lQ 4 �Year: f C( ' <br /> 2) Vehicle Vin #: 2 �k 173/LT4t �) Make/Model: 00,n G <br /> 3) State Decal #: 6) Color: Z2 rCiyr CC, , <br /> VEHICLE OWNER INFORMATION <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 /> COMMISSARY INFORMATION <br /> Business Name: C C, C C 0 rn <br /> Owner Name: 5'o9 Tty 41Y7 -/I-V C, <br /> Site Address: 35Y L C” • (�4V L(? \� T o C 1ti I o tv S*'k\1'� <br /> Street Address city <br /> Phone: (0,,q) CI kms-- /7 k c/ <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 disposalEl 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 /> 'N GO TCE CREAM <br /> Z22,-- • !g--- — `� 88 E.CARPENTER RD. <br /> Signature of Commissd Owner/operator Date ST TO1\T,CA 95215 <br /> HEAL'"TH_DE PARTMENT'�''' <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 />