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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): -TaCOS fat) r-lo <br />Address for Vehicle: 3 toiq 6ittc .k yhtyt pd txzttor 01,_ 53? b , <br />' <br />.1 <br />Siree Address City <br />License Plate #: 3 75-‘( q g 4) Year: <br />Vehicle Vin #: 1C--,VIA-1--P5a-V—L-10.33Nal+Make/Model: I 30 <br />State Decal #: OA- 6) Color: 'al& <br />VEHICLE OWNER INFORMATION <br />Name: CI e f a fa° fan rto <br />Address of Owner: a Hit ovamiore., V-Lott-iy\ /A 615-zoo <br />Street Address ) City <br />The mobile food facility shall operate out of a commissary and shall report to the commissary <br />operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of <br />discontinued, the permit holder must notify this office to make the necessary changes. Failure <br />office may result in p mit revoc ion and penalties. <br />at least once each <br />the commissary is <br />to notify this <br />Signature of Vehicle 0 erator Date <br />COMMISSARY INFORMATION <br />Business Name: 16cCu .) I.: 60 cksA f t.opsEs orcxt cf.i Nj t<ts-rksu c_ i...\ ivi <br />(3ao Owner Name: b e a,0 at( no <br />r <br />Site Address: E3.° Le- i-0 01 A M-0 bEST() <br />Street Address City <br />Phone: (M) 315-___ D-61._ct, I <br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned <br />commissary as checked below: <br />Utensil washing sink n Liquid & solid waste disposal 7 Store frozen food I I Vehicle or 3 compartments) <br />R‘reparation of food KHot & cold water for cleaning Toilet & hand washing fl Store <br />I I Store dry food/supp s M Provide potable water Overnight parking Adequate <br />z- s ZT.' <br />vehicle at my <br />wash facilities <br />refrigerated food <br />electrical outlets <br />Sig ature of Commis ary 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 /> <br />County. .---' 0 e f ..... <br /> <br />c.:... eA 4.4, /„../ ..A--/ <br /> <br />Signature of County RE HS Date <br />END 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008