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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all Information requested. An Incomplete application may delay approval. <br /> VEHIGENRf6-A'p ,��R.O . <br /> Vehicle Name(DBA): <br /> Address for Vehicle: , i S ill 9s�S_a <br /> street Address I city <br /> 1) License Plate M C)L4ly a G.1 4) Year: <br /> 2) Vehicle Vin M IYC3G, 5) Make/Model: FO fdI I'V111 <br /> 3) State Decal#: �? 3 a0 Lilt, 6) Color: Y1' LJ. l d < Blau <br /> Name: hc,. 3IGC5IwVt Ui-, <br /> Address of Owner: O'S--7 3rd 'Cr LA,_ t1r C'I"1 <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 /> s/ r� llc- <br /> Si nature of Vehicle Operator Date <br /> Business Name: <br /> Owner Name: <br /> Site Address: sS p L� DUo�If, 131vO'clR <br /> Saeel Address city <br /> Phone: (qjb)(,H 0 — )33- <br /> . I,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: II�� <br /> Liquid&solid waste disposal Utensil washing sink Store frozen food LT Vehicle wash facilities <br /> l3 or 3 Compartmental <br /> Preparation of food ®Hot&cold water for cleaning Toilet&hand washing tore refrigerated food <br /> Ica Store dry food/supplies L"V Provide potable water Overnight parking .Adequate electrical outlets <br /> Sli ��iL, <br /> Si nature ofrC .�ommissa Owner/Operator .mss Date <br /> �FIEALT;�iDCPQ,R7'MEf�Ti.`�.". E;�§"ek� ,k`r�' -.�'r`f`.irk'eus"�.'lynr�".'.t'l.T�.��x."3''.��H,' %,.'.t'�.,�`F.hi�,_'_�'n,i✓�i`dc '�'h'��,t#'„+,�r�fk,.�-t'J', <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 /> EHO 16-017 Sofa MFPU APPLICATION <br /> 7nenooe <br />