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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): 1,6) ea/ 6- fi.N <br />Address for Vehicle: Et-( 1 :3-'4 L etvi /AA- i 57c e. KrbAl in 75:2_ 0 7 <br />Street Address / City <br />License Plate #: 6,63 q,5-k_z_ 4) Year: / <br />Vehicle Vin #: 5) Make/Model: C7/61/ VA/ <br />State Decal #: 6) Color: t3P 6k-id L ,; , t ) <br />VEHICLE OWNER INFORMATION <br />Name: RL pa c 2 To 0_ c----75 <br />Address of Owner; 5 li 7 3 ALE-pi Li iv,/ 5-LK:V/ti, zi) 95,-> 6 T <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 in permit revocation and penalties. <br />Signature of of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name:' C) Ai C A- MT k I Al C) 7-Ru L -fr.. c EiLl "FET k <br />Owner Name: 5/ /'4/)O / ( R f I) 6 <br />Site Address: 1 7 i 7 6 , Li A.) / 0 Ai ,3-7-: ,5----jr, K__--rt 4,7, ./1 32C421 , Street Address City <br />Phone:( ) <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 /> iquid & solid waste disposalUtensil washing sink P/-Store frozen food PI Vehicle wash facilities (2 or 3 compartments) <br />, -7 <br />'IJPreparation of food j i/I Hot & cold water for cleaning Lioet & hand washing I-----Store refrigerated food 1 <br />i ,--,„, rj-Store dry food/supplies F171)rovide potable water I v-rOvemight parking r: .l'Adeq uate electrical outlets <br />e ,.../:-). r....„ ._7____„:_.:7_•• ____,_z <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. Commissary/food establishment is in <br />County. <br />Signature of County REHS Date <br />EHD 16-017 <br />5 of 6 <br />MFPIJ APPLICATION <br />7/18/2008