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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: i <br /> Street ddres f City <br /> 1) License Plate#: 66-�4.2o4q 4) Year: <br /> 2) Vehicle Vin#: �j" i��`� �d5(�9s Make/Model: �y� �u�161511 <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: iv/!Ge 52 <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 permit revocation and penalties. <br /> Signature o Tft cle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: s^' a <br /> Owner Name: g p <br /> Site Address: <br /> Street A dress city <br /> Phone: ( ) —A T <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 /> � y� <br /> Liquid&solid waste disposal u Utensil washing sink <br /> 2 or 3 compartments) V❑�Store frozen food ❑ Vehicle wash facilities <br /> dPreparation of food /Hot&cold water for cleaning WToilet&hand washing WStore refrigerated food <br /> ❑Store dry,food/ uppIies Provide potable water 0 Overnight parking Adequate electrical outlets <br /> Sin e o 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 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />