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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 />_ <br />---- Address for Vehicle: . , — , Street Address City - <br />License Plate #: 75 8 5 ...5 ,..., i 4) Year: <br />Vehicle Vin #: 1-) i'‘, T c2 'Z4) 2 iC 5) Make/Model: <br />State Decal #: 6) Color: <br />(A, Ipix5,w, E -I if ' • - IA ' - <br />' — <br />.„„ :„ ,,,, . Name: <br />Address of Owner: ___, <br /> La '(‘ 1 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 office may result in permit revocation and penalties. , - <br />Sicuiiature of Vehicle O•erator Date <br />, ,-- Business Name: ' <br />Owner Name: , , <br />Site Address: , <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 />II ensil sh Liquid & solid waste disposal Ut waing sink Store frozen (2 or 3 compartments) food 0 Vehicle wash facilities <br />Preparation of food >-Hot & cold water for cleaning fl Toilet & hand washing E Store refrigerated food <br />Store dry food/supplies Provide potable water Overnight parking Adequate electrical outlets - - <br />Si nature of Corn missa Owner/Operator Date , , .. ' • " ij . ., „, <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 RE HS Date — <br />EHD 16-017 <br />7/18/2008 5 of 6 MFPU APPLICATION