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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): <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin #: 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: 34�� A. C A� rj ni <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 per it revocation and penalties. <br /> � y-C:4/1 <br /> Si r+t-Fe hicle Operator Date <br /> COMMISSARY INFORMATION <br /> �. Business Name: Lj <br /> Owner Name: <br /> Site Address: / ke, LI/ / M l 2 <br /> Street Address City <br /> Phone: (, 10 . <br /> I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> ❑ Liquid&solid waste disposal ❑ Utensil washing sinkStore frozen food E-1Vehiclewash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food ❑ Hot&cold water for cleaning Toilet&hand washing Store refrigerated food <br /> ❑ Store dry food/suppli s ❑ Provide potable water © Overnight parking Adequate electrical outlets <br /> Signature ofsa 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 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />