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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name(DBA): 'Pc� n SCC <br /> Address for Vehicle: -,-o(p S N Nt,+ 1 ctm 9 S 20 <br /> Street Address city <br /> 1) License Plate#: CO K Q J lin (� Co 4) Year: 2 cc)2- <br /> 2) <br /> 2) Vehicle Vin#: Gi T FGI 1 S i2 7 2 5) Make/Model: (9n V-4 C- <br /> 3) <br /> 3) State Decal* I �O �O 6) Color: eU yyQ <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: Z�3�� �� �><0`( Q _ CkJl�l CTT-2( 2- <br /> Street <br /> TS2( 2Street 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: { C CT'P- <br /> Owner Name: 'kwvvl,�2� <br /> Site Address: cc S 20s <br /> Street Address city <br /> Phone: (Zoq) 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 /> i C.e LX Ptkyv <br /> (2 or 3 compartments) <br /> ❑ Liquid&solid waste disposal ❑ Utensil washing sink tore frozen4eod— ❑ Vehicle wash facilities <br /> ❑Preparation of food ❑Hot&cold water for cleaningoilet&hand washing tore refrigerated food <br /> ❑Store dry /supplies ❑Provi a potable water &YOSvernight parkingdequate electrical outlets <br /> 61 <br /> 19 bq <br /> Si ature of Commissary ner/O erator Date <br /> HEALTH DEPARTMENT <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 REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />