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1i <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all Information requested. An Incomplete application may delay approval. <br />T� —�n-•d�s",s•,.-:i ,wetlr'.81'"w.—ty�.:V:_+^,.!.-;' .,e..-.,..i.-mw•..v. ... .., .... �' <br />VEHICLE INFORMATION'" <br />Vehicle Name (DBA): <br />Address for Vehicle: '�` ' /) ).L i��') ) !'� (l (=-i <br />j" rl o 11-i <br />r <br />street Address City <br />(p <br />1) License Plate #: 4) Year:/9/7(..-- <br />2) Vehicle Vin #: 5) Make/Model: YQ Kon - h <br />2) <br />3) tate a #: 6) Color. d <br />IPA 116UNA, <br />D' <br />a <br />INFORATION • �: - <br />`VEHICLE OWNER M <br />Name: '; I / '•lil1�.( l�,_-jS<r <br />1 � -r<. ",i;•,r.�i_ ! - !) !) � .t. <br />Address of Owner: / , q1 R U1 1 Ic ' 1 ' ;6J.S !� ' '1 I ':J-? \ J <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 theneces ary changes. Failure to notify this <br />office a3tresult in permit revocation and penalties. <br />"jam i�/ 7 <br />0�\Nt <br />Signa6ar6rof Vehi ee Operator Date <br />`COMM SSARY INFORMATION'•''"''°`a'''"`"'""`""`�'"(�;`."�„•`°".w'�.���t''�]]t.. <br />Business Name: <br />Owner Name:!—t-JI) <br />. <br />Site Address: / �7 `V t ) <br />St re Address City <br />Phone: ) - <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 2 Utensil washing sink ❑ Store frozen food Vehicle wash facilities <br />(2 or 3 compartment) <br />❑ Preparation of food C�?/Hot & cold water for cleaning ❑ Toilet & hand washing ❑ Store refrigerated food <br />9/Ovemight <br />ElStore dry food/supplies P/Provide potable water parking Adequate electrical outlets <br />�m R ", %/i`7/ao(3 <br />Si nature of Commissary Owner/Operator Date <br />-.vim-4 _— <br />fi Tfi':Rt:'ri..rr;,^s• rC."l�al�,'�ler�0':. �fetAl1�' <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 1"17 5 of 6 MFPU APPLICATION <br />711812008 <br />