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VERIRCATION OF VEHICLE C•MM1SSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />VEHICLE INFORMATION <br />Vehicle Name (DBA): S-howl:\ s on --7 - he_ g...04... <br />Address for Vehicle: 2.(0, 2f.to N. kil t n ' 90 Cit4-7011 Crt <br />V <br />License <br />Vehicle <br />State <br />Street Address City <br />Plate #: q 1.,) x4 ki 03 4) Year: 2_01 1 <br />Vin #: c,45, A. Q33 (2 Ltk-A 5) Make/Model: /I— • VAtt-LE--b <br />Decal #: (ii- 6) Color: S7-eal/\4eS5 5' 7L-e4 <br />VEHICLE OWNER INFORMATION <br />Name: 5tovA ve, ? KA \ \ , v SF, --3 cA.0„..s <br />Address of Owner: \2_0 2._ Svy\ANN._e_4-NAe.A.A.) "c7 T-41.j..e__ - CI\ CISZ 10 .1,07)Y1 / <br />The mobile food <br />operating day for <br />discos ued, <br />of e II., re•.ul <br />I <br />Street Address City <br />facility shall operate out of a commissary and shall report to the commissary at least once each <br />cle. s"- .. ncl servicing (CalCode sections 114295 8: 114297). If the use of the commissary is <br />- permit holdzr must notify this office to make the necessary changes. Failure to notify this <br />n pe mit re 'cation and penalties. I <br />, _doe/ 5/2Virrr - .._..........4.,&_. .. ,if <br />Ilivw <br />...... .. .. ...-41"..._. <br />Sign'attsge,..1:44-ct4 Oper.tor Date/ <br />COMMISSARY INFORMATION <br />, r Business Name:I/kpivis WavegiR t/Ce Crnii.1 <br />Owner Name: een4 Clovm we,. <br />Site Address: /2a6 At a/a/ /4. vociel--04, 4 f52a.r <br />Street Address City <br />Phone: (Port ) 1166N624 <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 />Utens 112-lquid & solid waste disposal il washing sink Store frozen food Vehicle wash facilities (2 or 3 compartments) <br /> Prep ation of food 17 1-<;& cold water for cleaning Toilet & hand washing Store ' igerated food <br />Store dry food/ polies Provide potable water Overnight parking 1 Adequate electrical outlets <br />'2 / 5 1$ 8 Signature of Commissary Owner/Operator D te <br />HEALTH DEPARTMENT <br />If the commissary/food <br />current health permit <br />County. <br />establishment is outside San Joaquin County, the local health jurisdiction must verify <br />by signing below. Commissary/food establishment is in <br />Signature of County REHS Date <br />EHD 16-017 <br /> <br />5 of 6 <br />MFPU APPLICATION <br />7/18/2008