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TEt I * COMMISSARY <br />Please provide all information requested, An incomplete application may delay approval. <br />VEHICLE INFORMA I ION <br />' <br />Vehicle Name (DBA): <br />''o <br />Address for Vehicle: C) cUPrees <br />' / ` C o _.,.6[ <br />city " <br />1) License Plate #: n 802 % <br />4) Year: <br />2) Vehicle Vin #: <br />5) Make/Model: V0 <br />3) State Decal #: <br />6) Color: t5 rAm4,ES '5` Cc c �- <br />VEHICLE OWNER INFORMATION <br />Name: <br />NO <br />( kLCA)L b5 <br />112/9 K'� <br />Address of Owner:ZCO% <br />C I . '101C CA QS 7 6 <br />_ <br />Street A dress <br />/ City <br />The mobile food facility shall operate out of a commissary <br />and shall report to the commissary at least once each <br />operating day for cleaning and servicing (CalCode sections <br />114295 & 114297). If the use of the commissary is <br />discontinued, the permit holder must notify this office to <br />make the necessary changes. Failure to notify this <br />office may result in permit revocation and penalties. <br />h� Rc, � G ,� 1 � At 6, <br />`Y G <br />a 1 <br />Signature of Vehicle Operator <br />Date <br />COMMISSARY INFORMATION <br />3usiness Name: U46J 0 1 C 'F5 �G <br />i(��C CE Pi TE r� <br />Jwner Name: 441ZO 17nG Gi <br />Site Address:.6 . U/' ©; T, S <br />To vol f� <br />Street Address <br />'hone: - <br />city <br />r c <br />the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />:ommissary as checked below: <br />Liquid & solid waste disposal Dltensil washing sink <br />Store frozen food Vehicle wash facilities <br />(2 or 3 compartments) <br />Preparation of food EKot & cold water for cleaning <br />Toi et & hand washing Store refrigerated food <br />Store dry food/su plies Provide potable water <br />Overn'ght par ing R I/Adequate electrical outlets <br />signature of ommissai- Owner/Operator <br />Date <br />JEALTHr DEPARTMENT <br />the commissary/food establishment is outside San Joaquin <br />County, the local health jurisdiction must verify <br />urrent health permit by signing below. Commissary/food establishment is in <br />ounty. <br />ignature of County REHS <br />- <br />Date <br />iP7�j p�gF <br />16-017 5 of 6 MFPU APPLICATION <br />2008 <br />