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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): a C- VP(CJ' <br /> Address for Vehicle: 0 r i <br /> S reet Address city <br /> 1) License Plate#: (��,,��c_Sg(u 4) Year: <br /> 2) Vehicle Vin #: 13 So)5) Make/Model: G H E V <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: r�) 33a" v�c �v� Q V, p�rck C r� <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 /> offic result in permit revocation and penalties. <br /> t-71 /Zc/� <br /> Sig ture of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name:"Hlfkl <br /> Owner Name: M k <br /> Site Address: U S pa, f W 1-J <br /> Street Address city <br /> Phone: ( tq) <br /> I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below�ua:-,�(/ <br /> Liquid&solid waste disposal utensil washing sink Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> [reparation of food Q40t&cold water for cleaning dToilet&hand washing— Stare-refrigerated Food <br /> RN A C;ATERIN <br /> tore dry food/supplies Provide potable water [��vernight parkin <br /> 2440 S.AIRPORT WAY <br /> 1 STOCKTON� CA 95208 <br /> _ <br /> f� (209)466 9000 <br /> Signature of ommissa 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 /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />