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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): c 4 -t---c- izi NI 6, i11 A s 7---67R <br />Address for for Vehicle: z.42 6 0 --W---d „9 ro s DK fi PT- g ,5-0 7 S4/l/ Ts-,c- 9s736 <br />Street Address City <br />License Plate #: 5 v 92/ 73 2_ 4) Year: / 9 7 Y <br />Vehicle Vin #: 5) Make/Model: (1/-/&.(/ <br />State Decal #: 6) Color: AltV/ 7-6 <br />VEHICLE OWNER INFORMATION <br />Name: G biR A/ E vi— S 1NG -t-1 <br />Address of Owner: z62 c 6 -1--fl.-_- ti,) 0 o .0 5 o k 4 i p T 6-6 7 519,t, Ltc,5 6 9s7 3 6 <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 />___ <br />did/ -.n------ 6 <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: a pi 0 tti il7--6---4( yki & Tx 1, „ ( k c6 -1j <br />Owner Name: S4 i 4 De k 7jx4i)e <br />Site Address: 1 7 ( 7 s toti , DA ) 5 ) 5 re, c k -7--Nui (4 <br />20? ,-) 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 />.1 Liquid & solid waste disposalUtensil washing sink iore frozen food 1- Vehicle wash facilities <br />(2 or 3 compartments) <br />ri<paration of food FrF-lot & cold water for cleaning tilet & hand washing 5--Scre refrigerated food <br />agt-Pre dry f d/supplies r721:)royide potable water ail S--ie-rni ht parking ErA-c--lequate electrical outlets <br />, <br />..., — <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. Commissary/food establishment is in <br />County. <br />Signature of County REHS Date <br />END 16-017 <br /> <br />5 of 6 <br /> <br />MFPU APPLICATION <br />7/18/2008