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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): USTAADS <br /> Address for Vehicle: 14200 W Byron Rd Tracy CA 95304 <br /> Street Address City <br /> 1) License Plate#: 4VN9119 4) Year: 2023 <br /> 2) Vehicle Vin #: lF9BD1625PF529840 5) Make/Model: FRACTAL <br /> 3) State Decal #: CALIFORNIA _ 6) Color: REp <br /> VEHICLE OWNER INFORMATION <br /> Name: USTAADS LLC <br /> Address of Owner: 2185 s Dianthus Ct Mountain House CA 95391 <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 <br /> �and <br /> 1�penalties. <br /> 6/8/2023 <br /> Signature of Vehicle Operator Date _ <br /> COMMISSARY INFORMATION <br /> Business Name: Amuse Kitchen, LLC <br /> Owner Name: David Victor <br /> Site Address: 61 Rickenbacker Circle Livermore, CA 94551 <br /> Street Address City <br /> Phone: ( 925) 518-7817 <br /> 1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> ❑x Liquid&solid waste disposal x❑ Utensil washing sink ❑x Store frozen food ❑ Vehicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food 0 Hot&cold water for cleaning x❑Toilet&hand washing ❑x Store refrigerated food <br /> ❑x Store dry food/supplies ❑x Provide potable water ❑Overnight parking ❑Adequate electrical outlets <br /> Zia 1/lez 6/8/2023 <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 Ak_6_vvti-e_AcA_ <br /> County. <br /> �-g - 20-2_3 <br /> SignatOre of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />