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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name (DBA): C <br /> Address for Vehicle: - ` <br /> CJS'' OYl <br /> Stree Address C)ty <br /> 1) License Plate#: , ❑� 4) Year: <br /> 2) Vehicle Vin#: 3 i,� S) Make/Model: <br /> 3) State Decal#: 6) Color. c <br /> Name: <br /> Address of Owner: G <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 a 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 In permit revocation and penalties. <br /> Si nature of Vehicle Operator Date <br /> QUI <br /> Business Name: � � <br /> Owner Name: c <br /> Site Address: /11( - <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 /> Liquid&solid waste disposal tonsil washing sink ❑ Store frozen food ehide wash facilities <br /> (2 or 3 contparimenle) <br /> reps n of food of& water for cleaning �ve <br /> d washing ❑ Store refrigerated food <br /> rovide potable water arking quare electrical outlets <br /> for d food/supplies ) <br /> 1� <br /> nature of Commissary OwnerlOperator Date <br /> Gil �_ •enc �' R _• , ry F <br /> " N „ � v <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 1"17 5 of 6 MFPU APPLICATION <br /> 711 St2008 <br />