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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all irrf( ation requested. An incomplete apl [tion may delay approval. <br /> � EHICIE LNTFOR11iAION _.�''� = ' <br /> Vehicle Name (DBA): <br /> Address for Vehicle: �- / 95=gp-L <br /> Street Address City Zip <br /> 1 ) License Plate #: p� ,�rj�3 4) Year.- <br /> 2) <br /> ear:2) Vehicle Vin #:�(1G���Zf�P�0,3„�Zsm&) Make/Model: <br /> i) Stale Decal #: o) Color: <br /> Name:Oeyjg�L 'M 54 !e,90 /146 <br /> Address of ONvner: a, yyr�Q✓W b <br /> Street Address Citv Zip <br /> The mobile food facility shall operate out of a commissary and shall 4-eport to the commissary at least <br /> once each operating day for cleaning and servicing (CalCode sections 114295 & 114297). If the use of <br /> the commissary is discontinued, the permit holder must notify this office to make the necessary changes. <br /> Failure to notify this office may result in permit revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> Cb1«VIISS ARY INFOR��AfiION <br /> ,F <br /> Business Name.- <br /> Owner <br /> ame:Owner Name: <br /> Site Address: s'. -':7CZ> <br /> Street Address Cit} Zip <br /> Phone:(Z '7 �� Gil' / <br /> I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at <br /> my co ussary as checked below:` Liquid&solid waste tensil washing sink <br /> ❑Store frozen food ehtcle wash facilities <br /> disposal (2 or�compartments) — <br /> Preparation of foodof&cold water for cleaning oilet&hand washing Store refrigerated food <br /> St dry food/supplies roe•de potable water ernight parkingdequate electrical outlets <br /> igtlature of Conunissary Owner/Operator Date <br /> If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must <br /> verify current health permit by signing below. Commissary/food establishment is in <br /> County. <br /> Signature of County R.E.H.S. Date <br /> EHD I6-01; Page 8 of 9 MFF APPLICATION <br /> 5,17'2007 <br />