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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 .F Sdo C© E 64 cTm 57-CL <br /> Address for Vehicle: 5t:)pC p/ UtE /_,5/)i C l� 9 "Z <br /> Street Address city <br /> 1) License Plate#: l d-l yl 65- 4) Year: 2 C&l <br /> 2) Vehicle Vin#: 5) Make/Model: /►�{/f/U G <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: E2 I Z a9 ET S CR N4 ldP E Z ,#961 UR LE <br /> Address of Owner: 5-60 X02412- <br /> Street <br /> 02412- <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 114296 & 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 mmay result in permit revocation and penalties. <br /> finh IIJ-04 =�A6 � r3 J� 7 <br /> Si natur"f Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: UA1100,1 Z, 72FAIA16 7WUtfCk CCN TEk <br /> Owner Name: IL9& a <br /> Site Address: 1717s, WXI(®Af S — G,( plJ 9S,,7,94 <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 /> M<jquid&solid waste disposal 0-diensil washing sink Erstore frozen food D<ehicle wash facilities <br /> (2 or 3 compartments) <br /> Pre tion of food of&cold water for cleaning Toilet&hand washing rK Store refrigerated food <br /> Stored ood/supplies Provide potable water 2-overnight parking c�Haequate elechical outlets <br /> /3 / <br /> Si ature of Commissary 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 16-017 506 MFPU APPLICATION <br /> 7/16/2008 <br />