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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): CA ( # nA h LeA 6. 4/ 0 0 D illi e 5 <br />Address for Vehicle: ,2&,' (1./ F4 mit q (/6: ,5'T6,6_K:1-Em.).1" , Street Address City <br />License Plate #: iLb(t)e - POICOCF 4) Year: 2 013 <br />Vehicle Vin #: 5) Make/Model: No lite---)4 <br />State State Decal #: 6) Color: -5 iIi 1 id1C-5-5 577:. 6? <br />VEHICLE OWNER INFORMATION <br />Name: r-X00, 0 fi 0 pi n &IBE ,, 60 ill, 6-z_, fri-Ake&D <br />Address of Owner: 2 (,) g Iti rl y ( k trio (1JT- ii i 1 '6 ,57---0 ,-,,,7b ,, c_4 1 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 />ffice may result in permit revocatioir and penalties. <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: IA A)/ 016 0 7-6- k i N( 6 -rizi.kc_v_ c ego -7-,6-iik <br />Owner Name• FizI Vint. 7 , A, itpo <br />Site Address: I 7 ( 7 _5 . to,i( b to .5-- Tr- 5-1-o dq-c) id L 4 9S, Z e23 k <br />20 41 4 Street Address ) City <br />Phone: ( ) ook C11 -,5-q 1 <br />f. <br />I, the <br />commissary <br />r-/-Preparation <br />I 1/Store <br />commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />as checked below: <br />--1:iquid & solid waste disposal KUtensil washingsink Fl<re frozen food 1791\-/ehicle wash facilities I1 <br />( 2 or 3 compartments) <br />, <br />of food 06t & cold water for cleaning F4Toilet & hand washing Store refrigerated food <br />dry food/supplies 1-15-rovide potable water 1—'6yernight parking 1-41equate electrical outlets <br />, / 79' 4a/5v <br />Sig ure of Commissary Owner/Operator Date <br />HEALTH DEPARTMENT <br />If the <br />current <br />commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />health permit by signing below. Commissary/food establishment is in <br />County. <br />Signature of County RENS Date <br />EHD 16-017 <br /> 5 of 6 <br /> MFPU APPLICATION <br />7/18/2008