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VERIFICATION OF VEHICLE C•MMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): ,/57 kO /- /7-4. <br />Address for Vehicle: 4-/rge•,- Cs --o <br /> <br />D 1- '1i g- ' Wit/6- s-.7 q__-ro AI 1 9.6.2 4 <br />Street Address ) City <br />License Plate #: /It PI-3 l O 3 4) Year: ,2 0 d ( <br />Vehicle Vin #: 5) Make/Model: /9- Z. 11 EX <br />State Decal #: 6) Color: Ge6AJI <br />VEHICLE OWNER INFORMATION <br />Name: 19-4/n 6 6.--R77-pq z b ov 1 <br />Address of Owner: ifz/,,Z g"- c e_,TAV.< imi ye 6.--7-6 ..k To AJ cf? r 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 />42 4// 7 <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: (OW OA/ C/97-5k//d6 rk a 61 k rEAtleA <br />Owner Namc5/9-2. tice7N/2, lciie A D 0 <br />i Site Address: / 7/ 7 s , 4 i Aj / d /1) S i ,-.) I 6 ck7 6 Ai, G/T 957,z 0 6 <br />—2 D9 „ Street Address City <br />Phone:( ) a.1 ?5-51//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 />Utensil washing sink 1 14quid & solid waste disposal Ht-tore frozen food R--Vehicle wash facilities (2 or 3 compartments) <br />r-/Preparation of food 1---1-lot & cold water for cleaning [(Toilet & hand washing H/-Store refrigerated food <br />F-4t 'ore dry food/supplies HI-Provide potable water 1-K)vernight parking K-Adequate electrical outlets _ <br />' laq. /F/ 7 111101.11 11r <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 />END 16-017 <br /> 5 of 6 <br /> <br />MFPU APPLICATION <br />7/18/2008