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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): r71 E I[ C LA SNIE- L L C <br /> Address <br /> 6-/-- <br /> Street Address city <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin M 5) Make/Model: <br /> 3) State Decal #: 6) Color: 5719 //SLS_S STEEL <br /> VEHICLE OWNER INFORMATION__ <br /> Name: p G 6062 L141)4 R6AJ0 <br /> Address of Owner: ;2-22-2- 1'— /U 51 ,5`7-LD�6�C$ O <br /> C� �ZL <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 /> -302Gt ME+�ocz �Mr�tLEnln �cMC /3(1 7 <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: ut1'(o 7--,Q A/G 7-4qCk CE/vT�Q <br /> Owner Name: ,S LU d v <br /> Site Address: 171 Z S', f.> V d 4 S-r Sl D TDA C <br /> 2 07 Street Address City <br /> Phone: ( ) 2 $ - <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 /> [�JGquid&solid waste disposal D U[ensil washing sink <br /> r�(22 Store frozen food I--��Vehicle wash facilities <br /> ( w 3 compartments) <br /> Ea�p <br /> reparation of food I�not&cold water for cleaning r lToilet&hand washing Score refrigerated food <br /> Store dry foodisupplies Provide potable water u&emiighhtt parking Adequate electrical outlets <br /> 4 <br /> Si nature of Commiss Owner'Operator Dae _ <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 /> EHO 16-017 5 of 6 MFPU APPLICATION <br /> 7/18!11306 <br />