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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> THICLEINFORMATION <br /> Vehicle Name (DBA): n <br /> Address for Vehicle: <br /> 12 7- <br /> Street Address / city <br /> 1) License Plate#: 61� �� ! (J 4) Year: (" � <br /> 2) Vehicle Vin #: k t�3/Z���l� ) Make/Model: 00,/7 G' <br /> 3) State Decal #: 6) Color: <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 INFQRMATION m <br /> Business Name: {� �, C 'C (f C 0 m <br /> Owner Name: S'09 7 41-ri -'i N C l-/ ' I <br /> Site Address: 35�� L C'. L dV \� T o C 1� I o rvl c.� <br /> Street Address city <br /> Phone: cf Lt�—' — �7 ✓ 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 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 �Q Overnight parking\�Adequate electrical outlets <br /> PR IN GO ICE CREAM <br /> 5g8 E CARPENTER RD. <br /> Signature of Com missa Owner/Operator Date ST1-S:`OiV,CA 95215 <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 RE HS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />