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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): LI /4 -2, CA, E L.-CS „i) e: iii 1.-y <br />Address for Vehicle: 4/ 79 At J-A c./.c mit ) 5 /,..44, 577jt/ ci d T.5 - 2. /5 <br />Street Address ity <br />License Plate #:e - ( Rffi g 3 6 I 4) Year: <br />Vehicle Vin #: 5) Make/Model: N6XTN., 0/110/6-1/ <br />State Decal #: 6) Color: icrD <br />VEHICLE OWNER INFORMATION <br />Name: /9,6 A L SeRTO CA S MAraffi <br />Address of Owner: 117 ? q it jAc(< 7 -ba i e 41) 5' 7U cli _ . 5 - . 2 / <br />Street Address 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 in permit revocation and penalties. <br />(7,) / ? 4de.aleA,IA-b 5— 9- -la- et,a4., 6- / <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: (.,/ e (0, pi) cni-gliti 6 7-- <br />- <br />kuck ci(01---- k ...-.--- Owner Name: akriii/ji O / ( Kti Do <br />Site Address: / 7 / 7 5 . I,( Ai r 06 _5 z-r: 37-,g A)) C /1 <br /> <br />269 , Street Address City <br />Phone:( ) <br />1, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />1-4--quid & solid waste disposal Er/Utensil washing sink I-'gtore frozen food [/Vehicle wash facilities <br />(2 or 3 compartments) <br />EV'reparation of food 114ot & cold water for cleaning Toilet & hand washing r4tore refrigerated food <br />dry food/supplies Provide potable water FROcernight parking TrAdequate electrical outlets <br />4 V <br />Si ature 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. Commissary/food establishment is in <br />County. <br />Signature of County RENS Date <br />END 16-017 <br /> 5 of 6 <br /> MFPU APPLICATION