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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 f City <br /> 1) License Plate#: /�� �� 4) Year: <br /> 2) Vehicle Vin#: >��� f 5//sem y��_3 5) Make/Model: {/ LC <br /> 3) State Decal#: _ 'i`7` 6) Color: G� <br /> VEHICLE OWNER INFORMATION <br /> Name: a/ <br /> Address of Owner: 1 ,�y� - � <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-i,,lr, p rmit revocation and penalties. <br /> Signature of Vehicle Operator Dite <br /> COMMISSARY INFORMATION <br /> Business Name: ��' T �- � � — o C�'� <br /> Owner Name: <br /> Site Address: ti `3 ' Y��C) <br /> Street Address City <br /> Phone: <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 <br /> (2 or 3 compartments) Vehicle wash facilities <br /> ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> ❑ S re di�)foodlsupplies ] Provide potable water Overnight parking FK]Adequate electrical outlets <br /> Signature of ComnT)issa Owner/ erator Date /r <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 />