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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 (DSA): ©t .5 E )Q(f C LA lS(JE L L C <br /> Address for Vehicle: 22- ZZ E ( 5T 5 TO �� C�-- <br /> Street Address City <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal #: 6) Color: 5719 /IJLQF5 -5Tf—E'L- <br /> VEHICLE OWNER INFORMATION <br /> Name: p G 6U C 2 a9#1 6^11`) <br /> Address of Owner. 22-2-2- . /U S r DLA C fT 2�� <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. /1 7 <br /> -309-GG MyNtJEZ RCMC 13( I / <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: E{At(o Z' r2 #C Qc{Ck CLAJT7 f-2 <br /> Owner Name: S' Ll✓ ,(� 6 <br /> Site Address: 17 S. C/iv(d/IJ Sr s"D TZ)/t i"'1 <br /> ,207 Street Address city <br /> Phone: ( ) 2 $ --5 /6 <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 /> tg<iquid&solid waste disposal L_I Utensil washing sinkStore frozen food Vehicle wash facilities <br /> r 1 (22 or 3 compartments) r-7� <br /> Q PL_Ireparation of food not&cold water for cleaning Toilet&hand washing L S—tore refrigerated food <br /> Store dry food/supplies Provide potable water 01&emight parking Adequate electrical outlets <br /> /& <br /> Signature of Commissa Owner/Operator Da e <br /> HEALTH DEPARTMENT <br /> If the commissarylfood establishment is outside San Joaquin County,the local health jurisdiction must verify <br /> current health permit by signing below. Commissarylfood establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/16/2008 <br />