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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#: vi I 15`11 7 4) Year: G <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: - &34,76) Color: <br /> VEHICLE OWNER INFORMATI N <br /> Name: <br /> Address of Owner: 5 / ! S-3 <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 res t'n permit revocation and penalties. <br /> Si nature f Vehicle Operator Date <br /> CommrgSARY INFORMATION <br /> Business Name: �' � (' (�o,� �. <br /> Owner Name: r- <br /> Site Address: GA Q 0 C ` C). <br /> !_ Street Address city <br /> Phone: (ZC))) <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 f ❑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 /> ❑WrQ dry food/supplies ] Provide p le waterOvernight parking El Adequate electrical outlets <br /> Signature of Com isiary Owner/ rator 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 />