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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 <br /> Address for Vehicle: 2q Ho qA,.1 Y u-v CAc'Co t/ CA �(k3 <br /> treet Address City <br /> 1) License Plate#: U 4) Year: TID <br /> 2) Vehicle Vin #: 0)oage%odel: �-` ✓�( <br /> 3) State Decal #: 6) Color: w CTe <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: L/1 C <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 /> - lef;'&A�� I GL- <br /> Si re of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: A1*CVf �f.-- L l <br /> Owner Name: cti �r <br /> Site Address: Amf Pu. r <br /> Street Address city <br /> Phone: Q,& ) Z <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 /> �uid&solid waste disposal Utensil washing sink tore frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food Hot&cold water for cleaning oilet&hand washing 7Adeq <br /> e refrigerated food <br /> Stored food/supplies lies Provide potable water Overnight parking uat electrical outlets <br /> dry PP � <br /> S nature of Commissary O "J perator 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 />