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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />.ams, - -- � , - <br />Vehicle Name (DBA): <br />Address for Vehicle:�j <br />street Address City <br />1) License Plate #: D P q N 4) Year: 161 �S <br />2) Vehicle Vin #: I Q ON WD � 972,�g? 5) Make/Model: (/ EV <br />3) State Decal #: 6) Color:�� <br />Name: <br />Address of Owner: .� <br />, <br />Street Addrass city <br />The mobile food facility shalt operate out of a commissary and shall report to the commissary at least once each <br />operating day for cleaning and servicing (CalCode sections 114299 & 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 />offic mlay result i;7int revocation and penalties. /�d>- <br />� <br />l.( C� 0 i <br />Signature of Vehicle Operator Date <br />x-C�_1�Vi1S�ia►"fZ��FORM�fi1�ItiT,�- _ . , : -- _ _ - - - -- <br />Business Name: <br />_.. _ _ <br />u ' <br />Owner Name: _ - SAWo <br />Site Address: IM -S (Wirovnim <br />St. ELOW <br />street Address city <br />Phone: <br />1, the commissary owner, can and will provide the necessary facilities for the above mentioned veWcle at my <br />commissary as checked below: <br />Liquid washing sinkquid &solid waste disposal ❑Store frozen food Vehicle wash facilities <br />(2,dr 3 compartments) <br />separation of food [2�'/Ho & cold water for cleaning L of t & hand washing ❑ Slore refrigerated food <br />' Ovemight Adequate electrical outlets <br />dry food/sup s Pro e potable water parking <br />Si nature of CornNaOwner er for Date <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 60f 6 MFPU APPLICATION <br />711812008 <br />