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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: ��' eel, ti - <br /> Street Address City <br /> 1) License Plate#: 4) Year: 9� <br /> 2) Vehicle Vin#: /6j—)p 5) Make/Model: <br /> 3) State Decal#: }�" 6) Color: ' <br /> VEHICLE OWNER INFORMATIQ,N <br /> Name: <br /> Address of Owner._ rS' 4 C <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 /> (Avywat �'I/ulli�' <br /> Signature of Vehi Operator Date <br /> COMMISSARY INFORM TION <br /> Business Name: <br /> Owner Name: <br /> GC <br /> Site Address: "- <br /> Street Address city <br /> Phone: 6rro 9t) <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 KToilet&hand washing ❑ Store refrigerated food <br /> ❑ Store dry food/supplies ® Provide potable water ❑ Overnight parking ❑Adequate electrical outlets <br /> .Signature of Commi sary Owner/O erator 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 />