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RECEIVED H6S -ON M60 : 1 HH '0 [ 'AdV ;W1j P;AI ;D;� <br /> All ' VERIFICATION OF VEHICLE COMMI' S RV <br /> ENVIRONM'P91WP"41b' tttOformation requested. An incomplete application may delay approval, <br /> VEHICL <br /> -01WORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: (OM Co- e.5-2-44 0 <br /> Street Address city. <br /> , I C <br /> 1) License Plate 1= tAJ %A 3H 4) Year. 201�- <br /> 2) Vehicle Vin *.AqC �t �3 �t-kq�0�jrjp%ake/Model: cA <br /> 3) State Decal#: 6) Color: <br /> VEH7�. <br /> -.6 <br /> ipoE WNEM INFORMATION <br /> Name: <br /> Address of Owner: �tx,- 9�5220 <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 114296 & 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 /> H l-'2-0 ZjD <br /> Signature of Vehicle Oeralor Date <br /> COMMISSARY,INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: <br /> Street Address city <br /> Phone: (201 aGlr �?55r� <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 /> UT1U1,q-Uid&solid waste disposal UJ-Utensil washing sink <br /> (2 or 3 compartments) D-Store frozen food E3-V-ehicie wash facilities <br /> ❑ Preparation of food E21H-`ot&cold water for cleaning M-Toilet&hand washing [R-sl-t-cre refrigerated food <br /> 191's-tore dry food/supplies EB/Provide potable water Le<rnight parking O-Adequate electrical outlets <br /> Si nature of Commissary Owner/Operator Date <br /> HEALTH DPARTIVIENT <br /> ........... <br /> If the commissaryffood 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-C)17 50f6 <br /> 711812008 MFPU APPLICATION <br /> Z d90:l,0'07 <br /> ,Ol, AdV <br />