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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> Vehicle Name (DBA): - <br /> Address for Vehicle: 7Z:- <br /> Street Address city <br /> 1) License Plate#: 8'D 4) Year: <br /> 2) Vehicle Vin#:(�L 35 733oZ`T'�15 5) Make/Model: fir/ <br /> 3) State Decal#: 6) Color: <br /> all <br /> Name: _._. . ;.. . <br /> Name: <br /> Address of Owner: <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 /> Se, 1- Z(�2 <br /> Signature of Vehicle O erator Date <br /> COMIVIISSARY INFORMATION„ _ <br /> Business Name: l^ �� <br /> Owner Name: <br /> Site Address: <br /> Street Address City <br /> Phone: Z ! � 4fe pa7.1 Z ZLIZ <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 ❑ Store frozen food e icle wash facilities <br /> (2 or 3 compartments) <br /> reparatio f food �rovide <br /> ter for cleaning ®�eiter&�han�d washing Store refrigerated food <br /> tore fo d/supplies le water ® vern9C�' ight parkingdequate electrical outlets <br /> Si na ure of Commissary Owner/Operator Date <br /> -,��roP i e. <br /> FIEALTH DEPARTMENfi <br /> , <br /> . <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 Aftft <br />