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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> iV�E-I b <br /> Vehicle Name (DBA): L_ PuT <br /> Address for Vehicle �3 - S r �� <br /> otreet Haaress •--:•� ty <br /> 1) License Plate#: 1� 4) Year: <br /> 2) Vehicle Vin#: C ?L. D93016A5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> Nfij <br /> Name: 1,L <br /> Address of Owner: �Y <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 /> offic y result in ermit ocation and penalties. <br /> U <br /> Z;7-5 _ 216 I�1 <br /> Si nature of Vehicle Operator Date <br /> COIAMISSAF t O H <br /> rrb,.. <br /> Business Name: <br /> Owner Name: 01 VaU s <br /> Site Address: `5�2 <br /> h <br /> Street ddress City <br /> Phone.- 121� <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 /> quid&solid waste disposal Utensil washing sink <br /> (2 or 3 compartments) 3.1 Store frozen food Q Vehicle wash facilities <br /> �E?'_Prep tion of food Hot&cold water for cleaning Toilet&hand washing Stor refrigerated food <br /> Store dry food/supplies — ro/vide potable U� p e water Overnight parking Adequate electrical outlets <br /> S <br /> Signature of ommissa caner/Operator Date <br /> .,.,.�- A <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 5 <br /> 7/18/2008 MFPU APPLICATION <br />