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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Y <br /> Vehicle Name(OBA): LR MOW/ TAMU101- <br /> Address for vehicle: -J-6 0 S C 0 11 o YAM S O 0 <br /> Street Address city <br /> j 1) License Plate#: U�� 4) Year: <br /> 1 2) Vehicle Vin 5) Make/Model: -(/HEV <br /> 3) State Decal 6) Color. ' Q� <br /> �1�E11�+r�QV�N ,N�FORAIfA�fE2i� - _ <br /> s Name: min <br /> Address of Owner. 3 ' <br /> j Street Address City <br /> !l The mobile food facility shall operate out of a commissary and shalt report to the commissary at least once each <br /> 1 operating day for cleaning and servicing (CalCode sections 114293 & 414297)_ 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 /> i offic y result in p it revocation and penalties. <br /> Signature of Vehicle Operator Date F <br /> CO.1l�l�ilil$�ia►��r1�iFORNI�Tt©1�_,`- � _ _ __ <br /> Business Name: f4NIV, n ' <br /> ,, <br /> XO <br /> Owner Name:_.S v l �/ 11" <br /> Site Address: ' 0 (W]"fovnim st, <br /> Street Address City <br /> Phone: (Z061 <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehilcle at my <br /> commissary as checked below: <br /> �tensil washing sink <br /> quid&solid waste disposal (Ur 3 compartments) ❑ Store frozen food Vehicle wash facilities <br /> P eparation of food J�H 8�cold water for deaning L 'of t 8r hand washing ❑ Sore refrigerated food <br /> dry food/sup s Pro ' e potable water Overnight parking Adequate electrical outlets <br /> Si nature of Com Owner er for Date <br /> ARIIE j <br /> if the commissaryffood 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 />