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VERIFICATWN OF VEHICLE COMiISSARY <br />Please provide all informatiTirrequested. An incomplete applicatiWmay delay approval. <br />,. , • , ,, ,. <br />Vehicle Name (DBA): <br />/— <br />Address for Vehicle: ,7 <br />Street Address City Zip <br />r <br />1) License Plate #: <br />/ — <br />/--/ 766: 4) Year: <br />, <br />/9q4 <br />Vehicle Vin #: 1, , _ 'f . ' 5) <br />64 'b State Decal #: 6) <br />Make/Model: Nk6/Y 1 <br />Color: bill /-e, <br />, <br />' - - , , , <br />Name: ft) U`7 --/U OR /44RA) ,Lq <br />Address of Owner: els, ,•,--Rg ar? 11)Ry --2W1 re ile 1 A ,i6-6,,,,:. ,06i/Al_ <br />Street Address City lip <br />, <br />The mobile food facility shall operate out of a commissary and shall 'report to the commissary at least <br />once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of <br />the commissary is discontinued, the permit holder must notify this office to make the necessary changes. <br />Failure to notify this office may result in permit revocation and penalties. <br />- Signature Signature of Vehicle Operator Date <br />. , ,..), Pi <br />Business Name: ek-7,--R,„ 7 q -7...."----- Owner Name: / /'(-040-e_, <br />Site Address: t5-'t / /76 t: i ,7D e 6,7.5Y <br />LStreet A dress ity Zip <br />Phone:(f/--) L. c_ --- <br />I, the commissary owner, can and <br />my commissary as checked below: <br />I Liquid & solid waste 171/Utensil <br />disposal or <br />FP/Preparation of food H t — IdStore d , d/ polies .rovide Ap <br />will provide the necessary facilities for the above mentioned vehicle at <br />, <br />washing sink P/Store frozen food [71/ehic1e wash facilities 3 compartments) <br />& cold water for cleaning IP/Toilet & hand washing [X re refrigerated food <br />potable water nvernight parking I Adequate electrical outlets <br />--.6---- 67 Si: !Tire of Commissary IP, wner/Operator Date <br /> , <br />If the co missary/food establishment <br />verify 1, ref health er 1 .4 by <br />/*deli i 14 r .._ <br />is outside San Joaquin <br />signing below. Commissary/food <br />/County. <br />County, the local health jurisdiction must <br />establishment is in <br />i 'ix ki / <br />Signature of County R.E.H.S. Date 1 <br />EHD 16-013 <br /> Page 8 of 9 <br />NIFT APPLICATION <br />8/17/2007