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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name (DBA): <br /> Address for Vehicle: ( S, <br /> Street Address city <br /> 1) License Plate#: L?I- 4)) Year: <br /> 2) Vehicle Vin#: (y141 8 iv L73_6_132 <br /> 5 , Make/Model: C7 /�'( c- <br /> 3) <br /> 3) State Decal#: 6) Color: (AJ Ylis 04_ <br /> Name: 26AVEDRIA CADEP,4A Li <br /> Address of Owner: [� w,q ODE <br /> Street Addfess 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, t ermit holder must notify this office to make the necessary changes. Failure to notify this <br /> office ay res t iq per it revocation and penalties. <br /> Si ature o icle Operator Date <br /> Business Name: Q <br /> Owner Name: <br /> Site Address: <br /> Street Address city <br /> Phone: ( - G' oZU <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 /> LZ<Liquid&solid waste disposal tensil washing sink ❑ Store frozen food ehicle wash facilities <br /> (2 or 3 co aliments) <br /> ;�-�'Kr<eparan of food of&cold water for cleaning oilet&hand washing ❑ Store refrigerated food <br /> ood/supplies �oviideable watererright parking Adequate electrical outlets <br /> 02 ao��o/ <br /> Si nature of Commissary Owner/Operator Date <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 Aaft <br />