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VERIFICATION OF VEHICL(90MMISSARY <br />Please provide all information requested. An incomplete app-Eation may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): c47 /1/44 / ) C f-- Cie 6 7 4 /0 I <br />Address for Vehicle: „26 A.) LL"[ c7 14^42 <2 7ZC-k-il'Ill ( cK2('S <br />Street Address City <br />License Plate #: k--7t,;25; 4) Year: LX9614 <br />Vehicle Vin #: /C:";CF-Ci i,c)(S-21003rs-775) Make/Model: Cfr-i- ti - i/i7ti <br />State Decal #: 4.,{)--(7 6-'‘i_c— 6) Color: <br />VEHICLE OWNER INFORMATION, fr r , ,, <br />Name: A, /q / l ffil- le f I /01 -tc , <br />Address of Owner: e L I A C- / S ib tir-64; c 4 `k( 2 IC <br /> <br />Street Address City <br />The mobile .food facility shall operate c-J.tit of .zi 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 /> <br />-X -t--tQ. d i Z-d_'1'' k:- Clq VII / 2 <br />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION <br />Business Name: <br />iiOn , ce ream Owner Name:Vola NlIolvi V2626 N. West Ln Ste #K1100 <br />Stockton, California 95205 Site Address: (209)469-2626 <br />Street Addres(209) 469-2073 City ,9- k ri /3 <br />Phone: ()47 ?) 9 .33 / i Li <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 />--- .--' <br />I I Utensil washing sink Liquid & solid waste disposal FO-Sfore frozen food n Vehicle wash facilities (2 or 3 compartments) <br />ri Preparation of food I I Hot & cold water for cleaning I-Ic<•ilet & hand washing n Store refrigerated food <br /> Store dry food/supplies I I Provide potable water FX/v-ernight parking ri-,41/44ate electrical outlets <br />41 ,) , <br />L._ 1./. Z.4---A--'-' /---- / / / <br />) 2_ / I/ 1 / 5 <br />Signature of Commissary Owner/O,pefatOr 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 5 of 6 MFPU APPLICATION <br />7/18/2008