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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): <br /> Address for Vehicle: <br /> Street Address ity <br /> 1) License Plate#: ��i C7-1/�gcl(5 4) Year: 20(f <br /> ( 2) Vehicle vin#: Make/Model: Tic <br /> 3) State Decal#: 6) Color: <br /> i <br /> ' VEHICLE-OWNER INFORMATION &elt 2 <br /> } Name: <br /> 3 3 �/ TZ�r <br /> Address of Owner: 3 Y f' 1/� a Lylat e` <br /> Street Address city <br /> 1 <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br /> 1 operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of the commissary is <br /> 1 discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> off'c may result in permit revocation and penalties. <br /> Si nature of Vehicle Operator Date <br /> C.OMMISSARY.INFORMATI: N <br /> Business Name: <br /> Owner Name: <br /> Site Address: Z <br /> // //Street Address city ,/ <br /> Phone: (Zo ? /– — �77� Cell <br /> �7`-/ <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 /> iqrid8, olidwaste disposal tensil washing sink ❑ Store frozen food Vehicle wash facilities <br /> (2 or 3 c artments) <br /> of food Hot& ater for cleaning Toilet&hand washingStore refrigerated food <br /> ;"repa <br /> to ry food/supplies Provide potable water Overnight parking aKd—equate electrical outlets <br /> ke <br /> Signature of Commissary 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 />