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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE IN O � �"�>::. 7 .�, 4 �"`.:�.::�wIn'T.1 N <br /> ? y!A.. \ _ <br /> Vehicle Name (DBA): 7170 -/-7?,, <br /> L� <br /> Address for Vehicle: '-7D t t ' <br /> Street Address city <br /> m <br /> 1) License Plate#: 7z6 �d 4) Year: JJe-7T1 <br /> 2) Vehicle Vin#: /-0,D11F3Z 1ZOLJi3S©/d Make/Model: rim C <br /> 3) State Decal #: 6) Color: <br /> VEHIONO . �;CN ` iA � ��e N <br /> Name: L (l <br /> Address of Owner: N N C 1�s 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 & 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 hermit revocation and penalties. <br /> ZZI 7 <br /> Signature of Vehicle Operator Date <br /> COMMI6A AY 1, FORMATIONS r' r r, 4 y Y > t <br /> Business Name: <br /> Owner Name: 'S�, <br /> Site Address: <br /> StreetAddress City <br /> Phone: ( Z'2�)JU ��G l c> l 7 q/ <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 /> iquid&solid waste disposal tensil washing sink ❑ Store frozen foodicle wash facilities <br /> (2 or 3 c :artments) <br /> Preparation of food Hot&cowater for cleaning oilet&hand washing ❑ Store refrigerated food <br /> �-�Storfood/supplies �;Frovide potable water vernight parking equate electrical outlets <br /> 7 <br /> Signature of Commissary Owner/Operator Date <br /> if ft HEALTH D=PiA <br /> ARTMENT Y. b i _ r��y' �' <br /> Y1s ..m'Xce, <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 Aftmik <br />