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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): <br /> Address for Vehicle: S y T,),-It i„ <br /> Street Address City <br /> 1) License Plate#: 5616 ib� 4) Year: ( G(� <br /> 2) Vehicle Vin r 6; t)11 p3-7-iZI ;P-35GI ) 'Make/Model: GGew, Pao StzyJv� <br /> 3) State Decal #: 1091-1 6) Color: i3 <br /> VEHICLE OWNER INFORMATION . <br /> Name: c4c- I ,P' D k.-e- :.I <br /> Address of Owner: Zo L1 8 (-'a r iultie i C.c - "'0 i ( <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 /> SI`gnature of Vehicle O a or Date <br /> COMMISSARY INFORMATION <br /> n <br /> Business Name: Lzti I �.r lh - Ji wa `S'SGr <br /> Owner Name. <br /> Site Address: (N 5 <br /> Street 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 /> Liquid&solid waste disposal Utensil washing sink <br /> (2 or 3 compartments) M Store frozen food Vehicle wash facilities <br /> ® Preparation of food Hot&cold water for cleaning X Toilet&hand washing Store refrigerated food <br /> WStor�od/supplies Provide potable water M Overnight parking 5fl Adequate electrical outlets <br /> Signature of GorrinTissary Ownert0 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 /> � ' L lam- 2 -7 -15 <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />