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40 00 <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): 1l- G)+ <br /> Address for Vehicle: <br /> Street Address City <br /> 1) License Plate#: 9 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: 14AYRTUW iR- C—'i-rM 6-T <br /> Address of Owner. U -TKA 1 C V CA /7 3 <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 per ' older must notify this office to make the necessary changes. Failure to notify this <br /> office may result i e i revocation and penalties. <br /> ja1��11 -� <br /> Signat re of ehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: ilrj; <br /> -' <br /> Owner Name: ;, <br /> Site Address: Z�q qo , lkr' vr. we",-4' ` — n <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 /> �iquid&solid waste disposal �tensil washing sink Store frozen food [J/Vehicle wash facilities <br /> 3 compartments)re aration of food �or <br /> &cold water for cleaning Toile.&hand washing Store refrigerated food <br /> �P <br /> Store dry food/supplies �rovide potable water Overnight parking Adequate electrical outlets <br /> vS h <br /> Sig 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 />