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VERIFICATION OF VEHICLE CUMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> ,VEHICLE.INFORMATION: <br /> Vehicle Name (DBA):-V S t/ i� <br /> Address for Vehicle: �Ov At\. (54- . S 46 7). M odes C4 53W <br /> Street Address City <br /> 1) License Plate #: H�1-\�S � 4) Year: <br /> 2) Vehicle vin #: 5) Make/Model: <br /> 3) State Decal#: A)lp 6) Color: n`tz��Cl <br /> j VENICE_E QWNER INFORMATION.- <br /> Name: <br /> Address of Owner: ( Q IU. [t C ,dJ Y 4 C 53 <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 result in permit revocation and penalties. <br /> Or —_V —1.piq <br /> SiqVt&j of Vehicle Operator Date <br /> COMMISSARY INFORMATION,.. <br /> Business Name:CO/ d Sd fi4_ e .LNG. 41 i na r"rvr� <br /> Owner Name: Ar+vvO . aea . Man g <br /> Site Address: 5'00 J41, 54 . c54L. D HocjesG 635 <br /> Street Address City <br /> Phone: aoq 33 <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 E2 Utensil washing sink <br /> (2 or 3 compartments) Store frozen food Vehicle wash facilities <br /> reparation of food 2/Hot&cold water for cleaning E3/Toilet&hand washing Q store refrigerated food <br /> tore dry food/suppliesProvide potable water Overnight parking Q Adequate electrical outlets <br /> 8 a/ ' �� <br /> Si re of Commissa Owner/Operator Date <br /> ',HEALTH,DEPARTMENT <br /> If the commissary/food establishment is outside fan Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commiss61ry/food establishment is in <br /> County. AA <br /> �— <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />