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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: o w o I. <br /> - L 9 -z�JL <br /> Street Address City <br /> 1) License Plate#: 3 o gSci� 4) Year.- <br /> 2) <br /> ear:2) Vehicle Vin #: 3 C-FF <br /> °) m' �� Make/Model: <br /> 3) State Decal #: 6) Color: LLA t— <br /> VEHICLE OWNER INFORMATION <br /> Name: ' b « 7 L_J <+ (L-BS0 <br /> Address of Owner: of 0� , _ ( 2 C_ �v�L <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 perm revocation apenalties. <br /> 1 <br /> Si ature.o ehicle O er or Date <br /> COMWSSARY INFORMATION ` <br /> Business Name: o W ,z ID <br /> Owner Name: <br /> Site Address: I pa t,J _ -Z D I C,4- 9 Viz, 2� <br /> Street Address City <br /> Phone: ( ) <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 /> 6VA-( 1/jn, (3 <br /> ❑ Utensil l�— <br /> Liquid&solid waste disposal washing sink(2 or 3 compartments) E] Store frozen food Vfacilities <br /> ehicle wash ties <br /> ❑ Preparation of food ❑ Hot&cold water for cleaning ❑Toilet&hand washing ❑ Store refrigerated food <br /> ❑ Store dry food/supplies ❑ Provide potable water ❑ Overnight parking ❑Adequate electrical outlets <br /> q 13 f Y <br /> Sio4ure of Commissary Owner/Operator Date <br /> H ALTH'`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 /> Si nature of County F�EHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />