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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): C y , <br /> Address for Vehicle: 1(Lr, Y 0�' U S �C)C l <br /> Street Address city <br /> 1) License Plate#: s 41 Year: <br /> 2) Vehicle Vin#: 32� s35) Vake/Model: <br /> 3) State Decal#: 6) Color: ki/ ,`F C <br /> VEHICLE OWNER INFORMATION <br /> Name: A o ? J <br /> Address of Owner: ( ISL Sk C� Lu Y1 COO <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 of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: r r U <br /> Owner Name: yL, AL.r f-{- STZjG� , <br /> Site Address: �� �.✓I <br /> Street Address city <br /> Phone: ('Oc.9) 2 !� <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 sink tore frozen food Q Vehicle wash facilities <br /> (2 or 3 compartments) <br /> 19/preparation of food �ot&cold water for cleaning et&hand washing Zstore refrigerated food <br /> Store dry food/supplies Provide potable water � Ooviernight parking dAdequate electrical outlets <br /> Si natu e of Commissa 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 />