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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): L- S W ENS E <br /> Address for Vehicle: ,9 a t 1�C 5T pr $ 5 L �I>l ps2 6 7 <br /> street dress lcity <br /> 1) License Plate* 6X 713 91 4) Year: 19 Ely, <br /> 2) Vehicle Vin#: 5) Make/Model: M (f Y /U <br /> 3) State Decal#: 6) Color: �J# / Tc— <br /> VEHICLE <br /> CVEHICLE OWNER INFORMATION <br /> Name: Esu G E(Rmvt d G )'11 A( GOT <br /> Address of Owner: ?2 ST. T- STdG ! C d <br /> Street Address Clry <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 /> officem result in permitfetiocation and penalties. <br /> illi ] / 4 <br /> Signal re of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: U 0 TE C k CEN L P, <br /> Owner Name: p <br /> Site Address: 1717 S. (ON 577 Ock -D/d /4- 954(04 <br /> street Address city <br /> Phone: ( �) CZ F -S <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 /> Q Uquid&solid waste disposal 6/ensil washing sink <br /> (2 aJe mparenental Store frozen food 9-- ehide wash facilities <br /> reparation of food r oNro 'f&cold water for cleaning [Df ilet&hand washing [�'ore refrigerated food <br /> Stored od/supplies L e potable water �em'ght parking [9 Adequate electrical outlets <br /> / lIG <br /> Si na ure of Commissa Ow r/ erator Date <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 REHS Date <br /> EHD 16-017 5 of 8 MFPU APPLICATION <br /> 7/18@008 <br />