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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): 't .: Ck 1��t "L. <br /> Address for Vehicle: -2J4 '1 p IZ, c(Z T- � . /A r A <br /> Street Address -� City , / <br /> 1) License Plate#: yA � rr ,r �� 4) Year: �a X r/ <br /> 2) Vehicle Vin#: ?,H FZ-2 h0 Make/Model: GH LV`( <br /> 3) State Decal #: LIN 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: �,' P o <br /> Address of Owner-) 3*io" C- T12-EIIC1 CV S CIK TL), Cj� <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: <br /> Owner Name; RjN( fy I <br /> Site Address: ;�-000 <br /> Street Address city <br /> Phone: ItIt <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> dLiquid&solid waste disposal ❑ Utensil washing sinktore frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food i&cold water for cleaning EI/Toilet&hand w shing.� I. <br /> _♦tore-I�rj9erateH food <br /> Q Store dry food/supplies Wrovide potable water Overnight parkirig SLIC �dqualElnefle�t✓ I ocutFetsICC <br /> f 2440 S.AIRPORT WAY <br /> STOCKTON, CA 95206 <br /> ('%n'i)EB5 irOnO <br /> Si nature of Commissar Owner/Operator 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 />