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VERIFIC WON OF VEHICLE COCISSARY � <br /> Please provide all information requested. Ai incomplete application may delay approval. <br /> WW ICEE"INFORMATIONS ;"' '5,.� <br /> �:._ _ S <br /> Vehicle Name (DBA): eous(r, <br /> Address for Vehicle: <br /> Streetdo---- �1 City <br /> 1) License Plate#: (P Ul /-7 a U 1 i 4) Year: )-00 Z <br /> 2) Vehicle Vin#: `t v)h UGLO S 1(-I J&1fr Make/Model: Leek ISA(t4 �- lLL T L{ J <br /> 3) State Decal #: 2 Sa S2 I 6) Color: (3(C�c l� <br /> I _ <br /> �IEHICLEaOWNERtINFORMA710N `s�✓ " { °X'= ' ``''�a <br /> Name: <br /> Address of Owner: Zi,c�c1 (�c�Kew�a }�. G r� � vSe-u ts- -7 <br /> Street Address City <br /> The mobile food facility shall operate out of a commissaly 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 Fo make the necessary changes. Failure to notify this <br /> �,t:�rtay resulirtp�i avocet' nand penalties. I , <br /> Si na/t`ur✓e�ofCnVUe/h/iGe O erator <br /> Date <br /> COMIIIIIS'SAftY�NF:,ORMNUOR 'X "Yt� <br /> _ _ ir.- TMa n"n�. a.wc...+•'Y n}'6 ..�=. <br /> Business Name: v6ZICA g�a r , <br /> Owner Name: c,retV <br /> Site Address: !GD 2�cl,c_rJs xo(,✓d rye- Ce tm. <br /> Street Address City <br /> Phone: (9/�-)j 7 g 1 <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 /> Ciquid&solid waste disposal l-1 Utensil washing sink <br /> 12 or 3 compartments) �Store frozen food ElVehicle wash facilities <br /> EJ-preparation of food allot&cold water for cleanin aToilet&hand washing ostore refrigerated food <br /> Store dry food/supplies 'Provide potable water 2'Ovemight parking 21 Adequate electrical outlets <br /> Si nature of Co missa Owner/O erator Date <br /> HEALT;FI;DEPARTMENT y� " ' 3 :res" ' 6 RUN <br /> If the commissary/food establishment is outside San Joajuln 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 16017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />