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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): /R1?/6 R1? C-14 <br /> Address for Vehicle: 27D,5 Uf WMIAZE 14� 5 0C- lbi Q a`/ <br /> Street Address City <br /> 1) License Plate#: 72 3 53 S,( 4) Year: ( q <br /> 2) Vehicle Vin#: 5) Make/Model: G N61146LE7- <br /> 3) State Decal#: 6) Color: O ( TC <br /> VEHICLE OWNER INFORMATION <br /> Name: CSE jj,jHpER(JANflEz E EZ <br /> Address of Owner: td. Gp//LIE /J(/E. S)O(KT) L 9-Se C) <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 /> a( 31111-7 <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: alyleltl C l 6R!1L'G J—/UC C E/v rE/2 <br /> Owner Name: 5&b0&A7 *71-911,00 <br /> Site Address: /717 ,5. /0A) 57.- 5-77)Ck70n1, C.19 95a <br /> Street Address city. <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 /> u Liqu /id&solid waste disposal LJ Utensil washing sink <br /> (2 or compamnenis) Store frozen food ED/Vehicie wash facilities <br /> reparation of food [D Hot&cold water for cleaning 0'�oilet&hand washing ©Store refrigerated food <br /> Eq-6ticredryfood/supplies Provide potable water liO emight parking Q Adequate electrical outlets <br /> 3/1 // -7 <br /> Signature of Commissary Owner/Operator 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. Commissaryffood establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 Of 6 MFPU APPLICATION <br /> 7/18/2608 <br />