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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />- , <br />Vehicle Name (DBA): 1--Qnte jav s-1-014 <br />Address for Vehicle: 300 Ot M TM (lig /()A 06-2-4 <br />License Plate <br />Vehicle Vin <br />State Decal <br />Street A dress City <br />#: 4) Year: <br />#: 5) Make/Model: <br />#: 6) Color: <br />VEHICLE OWNER INFORMATION . <br />Name: 1 /4)0QV III <br />Address of er: /-,-DS" )\Akifiktirs Ma. v464 (jtjjj W b41131 <br />operA i ng <br />, co <br />. ir i <br />The mobile*.,od <br />Stree Address <br />facility shall operate out of a commissary and shall <br />dt . for cleaning and servicing (CalCode sections 114295 • tinuee, the permit holder must notify this office to make the <br />y rrA- utt in permit revocation and penalties. <br />111 5)Q4/q <br />LI City <br />report to the commissary at least once each <br />& 114297). If the use of the commissary is <br />necessary changes. Failure to notify this <br />Si • na ure of Ve ide Operator Date <br />:-..-- FORMATION7 • p. , c:., , , s„ , <br />Business Name: UP '1 <br />Owner Name: i . li <br />Site Address: 1?3, 1S 1\\I{1\\I{13r,, <br />EVtew --T(-- _bO45:5 <br />Street Address City <br />Phone: (elbb) Fg3 - h cf3S <br />commissary <br />Liquid <br />Eli Preparation <br />Store <br />I, the commissary owner, <br />as checked <br />& solid waste disposal <br />of food <br />dry food/su lies <br />can and will provide the necessary facilities <br />below: <br />Utensil washing sink Store (2 or 3 compartments) <br />Eli Hot & cold water for cleaning El Toilet <br />Provide potable water Overght <br />0 1( <br />for the above mentioned vehicle at my <br />frozen food Vehicle wash facilities <br />& hand washing U Store refrigerated food <br />parking Adequate electrical outlets <br />(--i- I I i fidi if A 1 I <br />na re of fill - sa 7 er/O•erator Date <br />%.• z <br />--:+71iaft.. 7.1,.. -- <br />If the commissary/food establishment is outside San Joaquin County, <br />current health permit by signing below. Commissary/food establishment <br />County. <br />the local health jurisdiction must verify <br />is in <br />Signature of County REHS Date <br />EHD 16-017 <br />7/18/2006 <br />MFPU APPLICATION 5 of 6