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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): Cp C`(E L. d E r UT R tQ &u E L <br /> Address for Vehicle: (b'p/ EEf"rr-i 5t ,l si. S'j6G9. ! C PSoZos <br /> Street Address City <br /> 1) License Plate#: 4) Year: d <br /> 2) Vehicle Vin#: 5) Make/Model: x'//19 PJa <br /> 3) State Decal* 6) Color: STS//�LFSS Sj EEZ <br /> VEHICLE OWNER INFORMATION <br /> Name: U C- Z F-ZLRCs D E <br /> Address of Owner: /8()/ E TEMEk56to 57- -51-Zc.XAI <br /> Street Address ICity <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 /> �aot�e\ Fore 5 -Aav-C--S- 717117 <br /> Si nature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: CZ-WlltI6 <br /> Owner Name: j L` Ao 6 <br /> Site Address: / -S , L( (QGd S% -5M (Q-dS„Z<q5- <br /> 7 0 Street Address city <br /> Phone: ? Q�' .S 'r- <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 /> E-liquid&solid waste disposal t�f tensii washing sink [&s ore frozen food U]Vehicle wash facilities <br /> (2 or 8 compartments) <br /> Q Preparation of food of&cold water for cleaning oilet&hand washing Q-slo-re refrigerated food <br /> 25-�Store dry food/supplies rovidee potable watervemight parking Adequate electrical outlets <br /> Signature of Commissa wner/O erator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verity <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 WPU APPLICATION <br /> 7n 8=08 <br />