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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): �� S V-0 <br /> Address for Vehicle: (� 10 <br /> AL, <br /> treet Address city <br /> 1) License Plate#: q�� G' 2 4) Year: 203 <br /> 2) Vehicle Vin#: , �'�Q - Igs 5) Make/Model: <br /> 3) State Decal #: n0CAg6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: DQ-- <br /> Street Address V 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 /> offi a re It in permit revocation and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION " <br /> Business Name: UA Do fv\W <br /> Owner Name: <br /> Site Address: v <br /> Street Address city <br /> Phone: (201) L -j�J- <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 ❑ Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food ❑ Hot&cold water for cleaning ❑Toilet&hand washing ❑ Store refrigerated food <br /> ❑ S dry food/supplies ❑ Provide potable water El Overnight parking El Adequate electrical outlets <br /> _Z 7 <br /> Si nature of Commiss Owner/O era 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 />