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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): _ — IS /(0 I Cc-_.•,s <br />. Address for Vehicle: ta3 (7 (,1 ,P// Pi /c6 I'll n /1,1' 7 f Fai , 01 ?16-732 7 <br />Street Address City <br />License Plate #: 4) Year: 2 0 / 0 <br />Vehicle Vin #:9- - A '<,.i 2 3 B p6---,8 R6),5-CFS' Y 5) Make/Model: /1.)6k)/i/ibli,5 :271;i)OLSTekr--:.; <br />State Decal #: 6) Color: ,Tbi/ 6 Z-e- 5-7 -7(-7-: <br />VEHICLE OWNER INFORMATION <br />Name: F - RE D frt c ot ,Q57- <br />Address of Owner: e/ / 3 9 VC t, pd/A PZ 4 e_.,, t - /?7,10,' 777-(4 c ht 7r33 7 <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 i permit revocation and penalties. <br />/75 <br />,,- <br />S atur of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: UN/ ON Cii- 7-6, -1-/ AlI CS 77l? tr' 4 c' CA -7--E-12 <br />Owner Name: , 5/i L I"' np(.),k / //p190 0 <br />Site Address: / 7 1 7 . L( ii,1( c, /LI ,e5'T -S- TocK •7"--(7 Al Cif (;),5--2- 0 <br />2 0 9", e„, Street Address /' city <br />Phone:( ) ,.., --15 --.__ Y/ 6, <br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />aKtensil 2 washing sink /Liquid & solid waste disposal P/Store frozen food Vehicle wash facilities <br />(2 or 3 compartments) <br />FKreparation Of food 17 l<ot & cold water for cleaning FIKoilet & hand washing F9/Store refrigerated food <br />. / <br />li Store dry food/supplies raOrovide potable water F-4‘ernight parking TriCkdequate electrical outlets <br />-.., ,1 <br />ei /i 7) --- <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. Commissarylfood establishment is in <br />County. <br />Signature of County RENS Date <br />EHD 16-017 <br /> 5 of 6 MFPU APPLICATION <br />7/18/2008