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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> `�/EIiICL+EINF©RMATION <br /> Vehicle Name(DBA): T C()St-a CA-foac e <br /> Address for Vehicle: Co8J�C) N C�q <br /> • Street Addrss / City <br /> 1) License Plate#: ( � {�25 1 v� 4) Year. f Gl U <br /> 2) Vehicle Vin* 5) Make[Model: <br /> 3) State Decal#: 6) Color. l/ G <br /> VEHI�LEOWIJER_ INF'0•RMATIOPIr_s���`?� ' ; ;,�;,����s� s�`°"+'" � ' '."s �, .;�'�'v � r.„s":'• <br /> Name: )D&X�iQ MMEICAO, A 7 \ek <br /> Address of Owner. \!AOS r 't dktcX� CA G Z <br /> LO <br /> Street Address <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 /> IDthth resuli in arm revocation and penalties. / / ^�� <br /> J Ill` (� S �IIInnVVnn`` �(/ y (l <br /> Signature of Vehicle rator Date <br /> XC©MMISSAR1'41NFURMATION "-4'T�77,17r;. ,� � °'-: 1 , '•"��"" ` _.'� "`.�'".^ "' '�'"'�"' -,q� <br /> Business Name: s <br /> 15'Q 4c <br /> Owner Name: <br /> Site Address: (o Zy <br /> Street Address z ���' <br /> Phone: (zct ) 21 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 /> 2Iquid&solid waste disposal �v[ensil washing sinktore frozen food r I <br /> (z or z compar6neots) ehide wash facilities <br /> ❑Preparation of food PIG&cold water for cleaning 0'foilet&hand washing Gg'o&re refrigerated food <br /> ore dry food/supplies / [9frovide potable water [Rgmight paridng equate elecbical outlets <br /> Sl nature f Commissa Owner/O rator Date <br /> r rye z tirF -rn-,^ sV em+7 : N .al <br /> '7 <br /> IE4LTH DEPARTMENT = ' <br /> .b:.s a.r.5'.{z t_s......' �'xye fit^ twb. '�7. '�,t',r: �°+.l f^-�•S�'a <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissaryflood establishment is in <br /> County. <br /> Signature of County REHS Date <br /> P.ND 16-017 5 of 6 <br /> 7178120-0 MFPU APPLICATION <br />