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VERIFIC ION OF VEHICLE CO mVIISSARY COpy <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: <br /> Street AddreCity <br /> 1) License Plate #: G�j 'T -_J-Z 7 _ 4) Year: ) v <br /> 2) Vehicle Vin #: rf P ]K2X 5) Make/Model: tq <br /> 3) State Decal #: 322-1 a--�;Z- ' 6) Color: <br /> s <br /> VEHICLE OWNER INFORMATION <br /> Name: �p� - �Q` O IG <br /> Address of Owner: I n naG'— = f\/OC'1 e-5R) c S ' <br /> Street 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 r in permit revocation and penalties. `� <br /> cS <br /> Signature—of Vehicle Operator Date <br /> COMMISSARY INFORMATION j (7,'-\LIFrO`N i A ( ATIF]RIf°j.. <br /> Business Name: ( i 30D ANE) JL-RVf E <br /> / <br /> C�i 2 i A-1 F>-Pt <br /> Owner Name: G ac <br /> Site Address: QrF <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 /> IM Liquid &solid waste disposal ® Utensil washing sink Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> FV Preparation of food ® Hot& cold water for cleaning Toilet& hand washing Store refrigerated food <br /> Store dry food/supplies , Provide potable water 4p Overnight parking Adequate electrical outlets <br /> Signature of Co— mfr 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 />