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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 <br /> Street Address GAY <br /> 1) License Plate#: //1� i1� 4) Year: <br /> 2) Vehicle Vin#: oZ/Y8 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE; WNER INFORMATION <br /> Name: <br /> Address,,6f 0 er. <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 /> Signature 6f Vehicle OL`erator Date <br /> COMMISSARY INFORMA ON <br /> Business Name.- <br /> Owner <br /> ame:Owner Name: �` tj <br /> Site Address: e. .�71�`_ G'/✓ S ��� <br /> Street Address city <br /> Phone: Q09 <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 /> ❑ Store dry food/supplies Provide potable-water Overnight parking nj Adequate electrical outlets <br /> IX <br /> =,� ✓ice< = <br /> Signature of Commissary 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 16-017 506 MFPU APPLICATION <br /> 7/18/2008 <br />