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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may dewy approval. <br /> VEHICLE INFORMATION i <br /> Vehicle Name (DBA): SCA-itiLivU- t S HC+` c) p.fes, <br /> Address for Vehicle: V ' <br /> Street Address City <br /> 1) License Plate#: `1 6-1)(� �g , 4) Year: <br /> 2) Vehicle Vin#: L C �U S 0 123 T 3 � 'IiCl- Todel: 0I�,r(T7 C <br /> 3) State Decal#: 6) Color: G�;VL(2SS 5 t <br /> _ .. � a <br /> VEHICL�OWNERINFORMATIONj"` - <br /> Name: ftZtZi <br /> a IPA <br /> Address of Owner: Q )Lu -(�- I IrL <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 may result in permit revocation and penalties. <br /> SC <br /> Si natur-�f-VGhi�la 9psratec_.-� Date - <br /> COMMISSARY INFORMATION <br /> Business Name: Sto JctLs K1006erhions Wonderful Ice +-,rear-n <br /> Owner Name: 2626 Westlane St#K110�: <br /> Site Address: 1 ,Ws�- �,it (209)469-2626 5 CiV D r <br /> I� street Address (209)469 2073 city <br /> Phone: Rlb% "/l C <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 /> ❑ Liquid&solid waste disposal Utensil washing sinkStore frozen food <br /> (2 or 3 compartments) ❑ Vehicle wash facilities <br /> ❑ Preparation of food Hot&cold water for cleaning Voilet&hand washing u store refrigerated food <br /> Store dry food/s plies Provide potable water 4�/Ovemight parking [�; 4dequate electrical outlets <br /> Sig&6tfdre of Commis Owner/Operator Date 1 <br /> HEALTHd rS (r R, M� �7 Yh97Jvq��4A+ <br /> DEPARTMENT t Y, e" L,V+wrn,e 1ge, <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 /> EHD 16-017 5 of 6 <br /> 7/18/2008 - N1FPU APPL6CATioN <br />