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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> kVEHICLE�INFOR�TI'�N :� <br /> Vehicle Name (DBA): ��„ /�� <br /> Address for Vehicle: — � � C �� <br /> Street Address City <br /> 1) License Plate#: �� �� 4) Year: <br /> 2) Vehicle Vin#: /�Dl� 356 5�) Make/Model: <br /> 3) State Decal{#: 6) Color: � l' <br /> , msaz 'moi <br /> 'N TIMOR ? a`' <br /> �" � <br /> ECL0ti #est.r - <br /> Name: Ra t ' <br /> Address of Owner: 1?S7 6018-e,#)oct L- Lu 5 <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 /> �a L,-C I 1k*rI - X1'/1/9 <br /> Signature of Vehic0 er r <br /> Date <br /> .C..MISS.p►. Rw t�_N�� RMAT �� "�0a Q. <br /> ,�: <br /> Business Name: L-e h I� <br /> Owner Name: J L cc dcjy �d +� <br /> Site Address: '30 F- - <br /> Street Aaciress City <br /> Phone: (Z to / <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 /> Utensil washing sink ❑ Store frozen food ❑�"�hicle wash facilities <br /> iquid&solid waste disposal (Z or s compartments) <br /> rep on of food VProvideopotable <br /> cwater for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> ver/ni h arkin dequate electrical outlets <br /> Store ood/supplies water L�J'� 9 `parking <br /> SI nature of Commissa Owner/Operator Date _ <br /> HEAL tN DEP RMENT �;A , ;r: �� `aY `' . <br /> .. �.�: ._ <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 /> 5 cf 6 MFPU APPLICATION <br /> EHD 16-017 <br /> i/1812008 la <br />