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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): D-MEATBARREL <br />Address for Vehicle: 1570 E F STREET OAKDALE 95361 <br />Street Address City <br />License Plate #: 4NK5262 4) Year: 2014 <br />Vehicle Vin #: 4YMCL1626EN015046 5) Make/Model: CRONT / CARRIER <br />State Decal #: 26079 6) Color: BLACK ___. <br />VEHICLE OWNER INFORMATION <br />Name: DONALD 1 DEGRAFF <br />Address of Owner: 508 DALES PONY CT. OAKDALE 95361 <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 />U.gtally sqlned by Donald J DeGraff <br />DN CN ., Donald J. DeGraff C ‘-- US <br />()WO 201506 28 13 S2 10 -0BCX:r 06 29 15 <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: Z_ 64, (p/r)/SCc2—i /e_s 7z-,-' <br />Owner Name: CC(C7/ Sway) <br />Site Address: 500 73- -HA cS ± jr) es-7--0 9_5- 35 <br />Street Address City <br />Phone: (.20) 338 366.3 <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 />1g sink 71-Liquid & solid waste disposal EJ Utensil washin ,,r- Store frozen food iVehicle wash facilities <br />(2 or 3 compartments) <br />21-Preparation of food Hot & cold water for cleaning .F" Toilet & hand washing Store refrigerated food <br />E Store dry food/supplies _2-Provide potable water 12/Ovemight parking aAdequate electrical outlets <br />//' IF ...- ,,,,, - <br />ignature of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local healffjurisdiction must verify <br />current health permit by signing below. Commissary/food establishment is in<1,-7,1,/,'; /4'.--e, ; C <br />County. <br />Signature of Coun y REF'S Date <br />END 16-017 <br /> <br />5 of 6 <br /> MFPU APPLICATION <br />7118/2008