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S' nature of C missa OwrigLIS_Verator <br />.ARTalteNT TH <br />giStore frozen food <br />pl Toilet & hand washing <br />VI Overnight parking <br />51 I 111 <br />Date <br />Vehicle wash facilities <br />Store refrigerated food <br />(71' Adequateelectrical outlets <br />5/1/24, 416 PM IMG_2032.jpeg <br />VERIFICATION OF VEHICLE COMMISSARY <br />Please provid• all information requested. An Incomplete application may delay approval. <br />Vehicle Name (DBA): <br />Address for Vehide: <br /> <br />(04 <br /> <br />Street Address <br /> <br />City <br /> <br />1) License Plate #: Chi q itag <br /> <br />Year: <br />Make/Model: <br />Color: <br />(101V Vehicle Vin #: <br />State Decal #: <br /> <br />VEHICLE OWNER INFORMATION <br /> <br />felt,' 1/3 <br />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). lithe use of the commissary is <br />discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this office may result in permit revocation and penalties. , <br />Signature of Vehicle Operator D te <br />5//20,27 <br />, <br />Name: <br />Address of Owner: <br />tit 14)4 <br />Street Address <br />COMMISSARY INFORMATION <br />Business Name: Cklti" .M) °Ay CA-nickge, <br />AL-Vw•cas ciofv.k.ty. LC <br />Raxic.c dc '5w) <br />Street Address <br />Phone: (011(., ) Lq <br />Owner Name: <br />Site Address: <br />&A.C.4.0.NrrtbAt, <br />City <br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my commissary as checked below: <br />{21 Liquid & solid waste disposal <br />Preparation of food <br />uPPhes <br />I-01 Utensil washing sink <br />(2 or 3 comportments) <br />Hot & cold water for cleaning <br />12 Provide potable water <br />If the commissary/food establishment is outside San Joaquin County, <br />the local health jurisdiction must verify <br />County, current health permit by algal below. Commissary/food establishment is in )cLi L <br /> <br />Signature of oun EHS <br /> <br />Date <br /> <br />cl40 16.017 <br />th/7004 <br /> <br />5 of MFPU APPLICATION <br /> <br />1 0S LI‘r'31-1Li <br />https://mail.google.com/moil/u/0/7tab=rm&ogbiffinboxNVhctKKZWmmTzWJrfOkwjMBFBzVCGhcGxRVgSLsSOSXXZwGXBCvwZtZGIbscVzXgTqWCI. 1/1