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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />' 'L-00tig:,INFOkii/lAtio*: <br /> <br />Vehicle Name (DBA): ?(Lac.A._S -1-ckCALAAT CCk <br />Address for Vehicle: (0'2_0 5 ,(..1 /4 ,p(vit y_k ko sA. . Lo , Ce‘ 015240 <br />Street Address City <br />License Plate #: (42 IN-NZ- S C 4) 4) Year: IGr°10 <br />Vehicle Vin #: #1_Ge)k\p2 KQL -y).251%- 5) Make/Model: C.:1-ke....\) <br />State Decal #: 6) Color: <br />- — . iNNEk- <br /> <br />VEI-ii.OLE; - — - ti\i0OiliiiikticiNi . _ , . <br />Name: ,,. 0 q- 'V, CAk- akk Q‘AcN <br />Address of Owner: 53 k,kpc,k\k 0 Lv 1..- v-\ . I— pa : c. e\ al 52_4 0 <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 />Signature of Vehicle Operator Date <br />COMMISSARY INFORMATION , <br />Business Name: Lo /44/24, • 5: .-ctty (59 <br />Owner Name: Ole/is/l ir& de-het._ <br />Site Address:6 Lo .s, ,----ce fp-zielz, -;---4- q 5- z ye, Le,:p, <br />Street Address City <br />Phone: (7 (1) Z7 /i39 <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 />Utensil washing sink 111.{:iquid & solid waste disposal 'frozen food PrCe-1--ficle wash facilities <br />(2 or 3 compartments) <br /> Preparation of food ra118, cold water for cleaning rikTglel& hand washing I-4'6;e refrigerated food <br />Z186re dry food/supplies 11.1-1<ivide potable water 7I-15'/-e-i---night parking [AM qics-7----late electrical outlets <br />z____ /e — /7 — / 9 <br />Signature of Commissary Owner/Operator Date <br />HEALTH,- DEPARTMENT <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify If <br />current health permit by signing below. Commissary/food establishment is in <br />County. <br />Signature of County RENS Date <br />END 16-017 5 of 6 MFPU APPLICATION <br />7/18/2008