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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: / Z9 67, & ap S <br /> Street Address I / city <br /> 1) License Plate#: 4) Year: �Ve S- <br /> 2) Vehicle Vin#: 5) Make/Model: AA <br /> 3) State Decal#: �� 7e6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: �i L11 <br /> Address of Owner: <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 result in permit rev . n and alties. <br /> 7" <br /> nature of Vehicle Op4rator Date <br /> COMMISSARY INFORMATION <br /> Business Name: Q� p� <br /> Owner Name: ` 'r <br /> Site Address: O <br /> rStreet Address city <br /> Phone: (2N) L-,- i,� 5 <br /> 1,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 t ❑ 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 /> ❑Stor dry od/supplies Provide potable water Overnight parking FK1 Adequate electrical outlets <br /> Signature of Commi (sary Owner/O e" r 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 />