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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): -7 -0,1e 0 &V/ /O <br />Address for Vehicle: 273S f mg u z.2, 1 ci , sr-ex...KT-NO e....A ?6---,2 0 <br />Street Address ) City <br />License Plate #: ,55 Liao 1—.2, 4) Year: i q83 <br />Vehicle Vin #: 5) Make/Model: (AT. <br />State Decal #: 6) Color: 6'kEe:A/ <br />VEHICLE OWNER INFORMATION <br />Name: \S it. Vi 0 6-6 p/ A/ 0 z li <br />Address of Owner: c.,2 - 7 3 .e.;- rim i f 2 z i cr. 5-7-,0 c i.(1-0 Al c 4 5z6 C <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, /result in ermit revocation and penalties. , _ .;, , <br />Signature of Vehicle Operator LI Date <br />COMMISSARY INFORMATION <br />Business Name: 4//1/7 0 A c A:: iq / 4)6 / ie Le ck <br />Owner Nam/ 7/7 6 . wh ofi j sT ,_.5.-riD q<Tavi, cL 93;26 e,.: <br />Site Address:5 „IL Vii OOP\ 1---/ 12 A D o <br /> <br />10? 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 />ij Rilltensil washing sink /Liguid & solid waste disposal g/Store frozen food M" Vehicle wash facilities (2 or 3 compartments) <br />11_ Preparation of food RTI-ot & cold water for cleaningLE efoilet & hand washing Er--S-tore refrigerated food <br />i: tore dry food/supplies Hicovide potable water . E/Overnight parking Firi/kdequate electrical outlets <br />------/ <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 RENS Date <br />El-ID 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008