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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMAT100-1 <br /> Vehicle Name (DBA): <br /> Address for Vehicle:��OL� <br /> Street Address wry <br /> 1) License Plate#: 9:7 1 (u b W 4) Year: tP <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: 7�- 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: ZUjCFS ti► ( "t '`\�� � <br /> Address of Owner: 0 L2 9 ( 2 2 ❑ )„ (4\11 <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 /> Si nature o e erator Date <br /> COMMISSARY INFORMATION <br /> Business Name: P ' Q1 Com, <br /> Owner Name: <br /> Site Address: <br /> Street Address city <br /> Phone: (2(;,A) Lek i, 1 <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 F�l 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 /> ❑ Store dry food/supplies ® Provide potable water Overnight parking Adequate electrical outlets <br /> Si nature of Commi sa Owner/opeint& 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 /> 7118/2008 <br />