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REGIA ® <br /> APR 1 1 2019 <br /> ENVIRONMENTALHEALTH <br /> VERIFICATION OF VEHICLE COMMISSARY-RMIT/SERVICES <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION )36c5S e96-5 <br /> Vehicle Name (DBA): fCSS ` (, <br /> Address for Vehicle: Z11-7t V. C g�73.3 b <br /> Street Address City <br /> 1) License Plate#: q K 27/ 4) Year: 20 (j <br /> 2) Vehicle Vin#: 4 k:Z-q) 1Z 5) Make/Model: <br /> 3) State Decal #: 6) Color: 1-/1 <br /> VEHICLE OWNER INFORMATION <br /> Name: ,' -ImC-7 k IffRUAA) &!G7— <br /> Address of Owner. r (� %j}�' L (.S /�'�h�U ' G GY 9SJ U <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 /> 4e-1 4//- � Z/// t i � <br /> 'Signature of Vehic a-Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: (-//(�(Ufi� ( � <br /> Owner Name: <br /> Site Address: U17 S /G/LJ -wS (: r Oc� (/ 29A2 <br /> �O cy Street Address City <br /> Phone: <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 /> Liquid &solid waste disposal I 6`ensil washing sink DSore frozen food E/1 Vehicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food [D-Hot&cold water for cleaning [E]/Toilet&hand washing `' Store refrigerated food <br /> Store dry food/supplies aProvide potable water 1 /Overnight parking ©Adequate electrical outlets <br /> Signature of Commissa Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissarylfood 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 /> EHE 16-017 5 of 6 MFPU APPLICATION <br />