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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name (DBA): p t <br /> Address for Vehicle: � Q S Ssto(A<M <br /> Street Address city <br /> 1) License Plate#: 0 4 2 r 4) Year: Lgoi4 <br /> 2) Vehicle Vin#: III D tL—�9_�� NCAJ'%ake/Model: ( I <br /> 3) State Decal#: �/ 6) Color: <br /> Name: <br /> Address of Owner: Q WIN- <br /> Street <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'fi pe mit revocation and penalties. �� <br /> I 4� Z9 <br /> Si n ure of ehicle Operator Date <br /> y_yx4., " <br /> CQlYIiY1�C11 IY "'��:#i� "£-Y h" al^FFtuk '�'+ '�i•`' .fc'is"i,. t' s. ,.,A" y.. <br /> Business Name: <br /> Owner Name: <br /> Site Address: O <br /> Street Add res� ^^ City <br /> Phone: (�d <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 /> �L'i <br /> d&solid waste disposal /Hot <br /> nsil washing sink ❑ Store frozen food Vehicle wash facilities <br /> r 3 compartments) <br /> aration of food &cold water for cleaning Toilet&hand washing ❑ St e refrigerated food <br /> dry food/s lies rovide potable water Overnight parking Adequate electrical outlets <br /> gl <br /> ture of a Owner/O erator Date <br /> s• <br /> R <br /> • ..`1 1- <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 /> END 16-017 5 of 6 MFPU APPLICATION <br /> 7!18(2008 Aftw <br />