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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): LW u. <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: V[a 9 4) Year: <br /> 2) Vehicle Vin#: y f4 QU/14,�t6 jS�)gyp 5) Make/Model: <br /> 3) State Decal#: 6) Color: c <br /> VEHICLE OVYNER INFORMATION <br /> Name: - <br /> Address of Owner: ()111-'7 <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 /> discontinu , the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> officem sult in.permit revocation and penalties. <br /> Si na ure of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 6�L i XpyL, <br /> Owner Name: <br /> Site Address: rj{Ja ; 4A ew gsaas <br /> Street Address city <br /> Phone: (, L /-/S <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 ® utensil washing sink Store frozen food P<1 Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food Hot&cold water for cleaning ®Toilet&hand washing ❑ Store refrigerated food <br /> ❑ St ry food/supplies Provide potable water NrOvernight parking Adequate electrical outlets <br /> A� <br /> e' <br /> Signature of Commi sary Owner/Oi3ekatd Dote <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 /> 7/1812008 <br />