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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> �/EHIC1L•_'E^)t'I_4Nt'F_ytOCaRrMATlQN , a .. fNN <br /> ARM— <br /> Vehicle Name (DBA): <br /> j W <br /> Address for Vehicle: S S 77<f 4 Gi/ C-26S <br /> Street Address city <br /> 1) LicensePiate#: /)A/4,— 4) Year: dr/�Q <br /> 2) Vehicle Vin#: �,¢ x --? 5) Make/Model: txvg j - <br /> 3) State Deca)#: / _/� 6) Coior: S7 rl S L� <br /> ��twa.-... ?`n+v .i:`%.rca.t-_•n4:_;,; `s.w.N, <br /> VEHICLE OWNER>INFORMATION :„.�� •< it fi ., r tip eA3 ^`' m ;' w <br /> ti..i ...-.. _..s.�_S�_._._, � F$ i n.rnli`t�. v?t 3lcvt.110'.- 3 ..✓n.1�'.. :,=aSre Zak:....>.1h'S <br /> Name: 9 A .1 <br /> Address of Owner: � 26 <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 /> fficce may result in permit(revocation and penalties. <br /> &-5�S —C NI 69 d 02(4 2— / <br /> Si nature of Vehicle Operator Date <br /> araw.+•-.`. 2F+'"�A, +5p '457"1 ••,-. ar x s C a t+c Y ztrlly.. <br /> Lo 0M <br /> u.,f .r's`. y. 't <br /> Business Name: 3772 G1C ill (!)D Af" LCL (f Ae a?o <br /> Owner Name: e2/1ee �{ <br /> Site Address: /u• I,tJ L�� ( �/J�1/t �0�5 1'DC s C7 <br /> Street Address city <br /> Phone: ( — <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 /> ❑ Liquid&solid waste disposal tensil washing sink Store frozen food El Veehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food of&cold water for cleaning Toilet&hand washing 0-9fore refrigerated food <br /> ❑Store dry food/supplies [;I:�rovide potable water0vemight parking Adequate electrical outlets <br /> 1� cG� - 2l0 <br /> Signa ure of Commissary Owner/Operator Date <br /> rF'IELh`M�"°t ¢+rc.�.sy}^.Ci�Rat,:n":•rbt v:3r py#„v^,�J - i�'1 - g 1 ,a s i .fF1e _ R S a�"th'TJ� rx"c:g.}�•''� �r .,n >�rl fi-Ts.i' <br /> ALaTH'�( ERARTMENTn,:� t�n v,?s•'../ s � "{lfK*�. ,a'�?r� u >� .Y' �a sw t�•:r* av tiro . n Stt f-: <br /> ',....c__m+1.F_ l,!.,.1.J.......�x,.uA.tTS.. w ,..{�. F,/%F.LK.,'�t •,�,-�14v...�`.. ..15?"..SEt:+� x...: tri <br /> .... '.. .. ,.�*,z•(c......,,adSYt.A,1 . .Y.i's.9r�.�:..,�,:-. <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 WPU APPLICATON <br /> 711812008 <br />