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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): f613S L /9 6 i/ e- tehlfi I\ I AS <br />Address for Vehicle: 57 60 itt 6 0 9 y wi 77 5Th e_id-b61 cA Qs-2 / 2__. <br />Street Address City <br />License Plate #: VW Y.4. 63 ( 4) Year: ,2 (b 2-/ <br />Vehicle Vin #: 5) Make/Model: <br />State Decal #: 6) Color: &/) a t S rNALC-55 511- , <br />VEHICLE OWNER INFORMATION <br />Name: L.- t4 IS 17,1Usa0 F48(01:4 6LE GueRA <br />Address of Owner: 5/00 N #01' 9? Kr / 7 7 -r *To M, C A- K5-02, 1 2. <br />The <br />operating <br />discontinued, <br />office <br />Street Address City <br />mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br />day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br />the permit holder must notify this office to make the necessary changes. Failure to notify this <br />may result in permit revocation and penalties. <br />)67.(1 uo 00?-?, 7 /. / / g- <br />D <br />ignature of Vehicle Oprator Date <br />COMMISSARY INFORMATION <br />Business --rx - Name: i mi(0 rj 0:_iii /at i iftJ & a c x6 - - A] 'TER. <br />Owner Name: (5,1z: anc, 4 --7-710 4 46 <br />Site Address: / 7 / 7 sy ., 0,0 p Al s---a: 1 /4 c1-6) CKTP /1.9) C ill 96-2 0 <br />21r)Cf Street Address City <br />Phone:( ) ,Z 9 F -.510,c <br />I, <br />commissary <br />F9 <br />P4ry <br />the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />as checked below: <br />Utensil washing sink PrLiquid & solid waste disposal F97;ore frozen food PEK-/ehicle wash facilities (2 or 3 compartments) <br /> 1<r eparation of food <br />food/supplies <br />Hot & cold water for cleaning 117' ilet & hand washing PI/Store refrigerated food <br />tore d Provide potable water Ovemight parking 1-1-;deguate electrical outlets <br />Signature of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <br />If <br />current <br />the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />health permit by signing below. Commissary/food establishment is in <br />County. <br />Signature of County REHS Date <br />EHD 16-017 5 of 6 MFPU APPLICATION