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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all Information requested. An Incomplete application may delay <br /> . . . <br /> - - , <br /> approval. <br /> EHICLE 1NFORMA [OW - <br /> Vehicle Name (DBA): <br /> no -Iq -0 <br /> Address for Vehicle: 2, 606 G 's-FoLkToxf. 0 <br /> Street Address city <br /> 1) License Plate#: / 6-(l 4) Year: 1976 <br /> 2) Vehicle Vin * CPL 3S-63,-3j6e20 5) Make/Model: 61YEV <br /> 3) State Decal#i 6) Color: T-'�� <br /> % - <br /> EHICLE WNER NFdFiAAT(0W"1 <br /> Name: YOUM ARPUG-dAJ &M TLM0 <br /> Address of Owner: 2(,0(, 4MY 6TO(--k-170A, CA 9S2 C) 6 <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 /> 1 0 //9 45 <br /> Signature of Vehicle Operator Date <br /> 'C""'0 j�sMy. ,W=6AMAT <br /> mm io'k <br /> Business Name: 1e'1t1fi9AJ <br /> Owner Name: sF7L (/#,0bk -7-7P,9,00 <br /> Site Address: J-717ap PJ j5-ICC 1c-TQjg C-If <br /> '> &p ��- 5-T Street city <br /> Phone: ( ) 2!t Y -S- <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> EJ'Liquid&solid waste disposal 13-15iensif washing sink <br /> (2 or 3 compartments) 2igtore frozen food ErVehicle wash facilities <br /> RPreparation of food 2<01,t`&' cold water for cleaning D--Toilet&hand washing �Store refrigerated food <br /> EaStore dry food/supplies rrovide potable water <br /> acivernight parking []Adequate electrical outlets <br /> 0 ?As <br /> Signature of Commissary Owrier/Operator Date <br /> N- <br /> H1 <br /> if the commissary/food estabiishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissaryffood establishment Is in <br /> County. <br /> Signature of County REHS Date <br /> EHO 16-017 5of6 MFPU APPLICATION <br /> 7/18/2008 <br />