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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: _ G <br /> S reet Address Clty <br /> 1) License Plate#: 83 733— c4 Year: _ <br /> 2) Vehicle Vin#: /�7'DG6c//�y1��TyS1 L-�38 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> oVEHICLE OWNER INFORMATION �XeSer1�GT ' 7� <br /> Name: 5j62 <br /> Address of Owner: <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 in permit revocation and penalties. <br /> Pure of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: <br /> Street Address City <br /> Phone: �o _9.7-U 2a 9 7 � <br /> f,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> quid 8,solid waste disposal Utensil washing sink ❑ Store frozen food ehicle wash facilities <br /> (2 or 3 compartments) <br /> reparation of food of& d water for cleaning oilet&hand washing ❑ Store refrigerated food <br /> for ry food/supplies Provide potable water vernight parkingequate electrical outlets <br /> Si nature of Commissa Owner/Operator Date <br /> HEALTH DEPARTMENT <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 <br /> r <br />