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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />�VEHICLE:INFOfiMATlO1V _` <br />Vehicle Name (DBA): <br />Address for Vehicle: <br />�` <br />d r) <br />Street Address city <br />1) License Plate #: ±P M 7?)1 4) Year: 2-0 i LQ <br />2) Vehicle Vin #: CJ� 5) Make/Model:)?(,/INS <br />3) State Decal #: Cj 6) Color: Sfi� n I e S S <br />VEHICLE OWNER'_INFORMATION(' <br />Name: <br />lS <br />Address of Owner: T <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 lder_m`t notify this office to make the necessary changes. Failure to notify this <br />office may resulfii ermit revocation nd penalties. <br />Sin ure of Date <br />_GO . ISSARY INFORMATION <br />Business Name: <br />Owner Name: <br />Site Address: (Ailfuriqlm <br />Street Address City <br />Phone: (ZOT21-014i <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 />l <br />❑Liquid &solid waste disposal Utensil washing sink ❑Store frozen food , Vehicle wash facilities <br />� r3 compartments) i <br />50 PF eparation of food Hqt & cold water for cleaning To let & hand washing ❑ Store refrigerated food <br />Sto dry food/s S. '° RPravide potable water acivemight parking Adequate electrical outlets <br />S Lure of g n-issa Owner/Orator Date <br />HEALTH DEPARTM€NT <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 />7/1812008 <br />