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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): Et- s/ ZO NSE <br /> Address for Vehicle: ?OZ l QLUCICYST 1 W E " b C xfU dW Q.S,Z 6 7 <br /> Street Address lcity <br /> 1) License Plate#: 6 X 7 13 5 ( 4) Year: 19 g?, <br /> 2) Vehicle Vin#: 5) Make/Model: ( fA C )/ /U <br /> 3) State Decal#: 6) Color: (IJ/f / Tc— <br /> VEHICLE <br /> EVEHICLE OWNER INFORMATION <br /> Name: 5.E51,t GE(�ixlml G E i k GOT <br /> AddressofOwner: .22 Ls ST. T # S7aG �) C S b <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 m result In permit a ocation and penalties. <br /> 11117114 <br /> Si nature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: V 0 TE C Cgf/ EoQ <br /> Owner Name: 0 O <br /> Site Address: 1717 5. (o i(1 5 572%-j<-r6 d � 1,5-46Z <br /> Street address city <br /> Phone: ( �) 02 F -= <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 /> quid&solid waste disposal L=� 6tensil washing sink <br /> 12 or s compartrnenm) ET-st�ore frozen food ehide wash facilities <br /> Ly'r'reparation of food eot&cold water for leaning toilet&hand washing Store refrigerated food <br /> Store d od/supplies � ' e potable water Ovc7/ 74� <br /> ' ht parking Adequate electrical outlets <br /> Signature of Commissary Ow r/ erator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verity <br /> current health permit by signing below. Commissary/food establishment is In <br /> County. <br /> Signature of County REHS Date <br /> EHD 16017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />