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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): Rci) FR0 G <br />Address for Vehicle: (6 /Se, .1-te 0 Effikl 06/11Ce 411, iiiaiRop ell 533 t2 <br />Street Address City / <br />License Plate #: 25/ 0 C. VII 4) Year: 2.0C -3 <br />Vehicle Vin #: 5) Make/Model: DO 00 <br />State Decal #: 6) Color: G RE-Ea <br />VEHICLE OWNER INFORMATION <br />Name: fl e ime cks tailL,00 cuaum <br />Address of Owner: 1615 c) iNter6161)-tNicE iiv z mop C4 9533ô <br />Street Address 1 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 permi revocation and penalties. <br />/ <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: ii il/ i c, 03 1-7-E4j orcl 6,:. -T-g bi c k_. <br />Owner Name: ,.../1 L vibik-rrieft -A 10 -t: <br />Site Address: i 7/7 ,.5 , It Al co cci 5r- 5T- 0 ckTe et4 e# 9 S- Ze 2 4, <br />.r aa 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 />tensil washing sink I Cl'riquid & solid waste disposal 1Z--"g/Jore frozen food I-K.-Vehicle wash facilities (2 or 3 compartments) <br />EKreparation of food E - ot & cold water for cleaning likKet & hand washing rore refrigerated food <br />Store d ood/supplies Ride potable water [2 j<temight •arking RI'dequate electrical outlets , \ . <br />Signature of Commissary Owner/Operator Pate <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 RENS Date <br />END 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008