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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): MWME Wil illlO <br />QNN o <br />Address for Vehicle: 9M A <br />1 16;i Vi � <br />SOi� N�, , 1❑ <br />Street Address <br />City <br />1) License Plate #: A RV <br />4) Year: <br />2) Vehicle Vin #: �/� �� tp' Q i <br />5) Make/Model:GN� <br />3) State Decal #: <br />6) Color: lr 9 roe <br />VEHICLE OWNER INFORMATION <br />�'❑.� �— 0`' it ? ','p 0 <br />Name:, •� <br />Address of Owner: �f 0! ui0✓F <br />_> t(� <br />Street Address <br />City <br />The mobile food facility shall operate out of a commissary <br />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 <br />make the necessary changes. Failure to notify this <br />office may result in permit revocation and penalties. <br />Signature of Vehicle Operator <br />Date <br />COMMISSARY INFORMATION <br />Business Name: <br />( I,1 1 <br />Owner Name: VV19ff <br />''ll'� <br />Site Address: 1 1( V ! • <br />Street Address <br />City <br />Phone: (20' ) ,�"� �� % 2G 1 9 S 9 _ 4S2 S <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 />EZ Liquid &solid waste disposal 0 Utensil washing sink❑ <br />Store frozen food❑'Vehicle wash facilities <br />(2 or 3 compartments) <br />Pr paration of food 9r Hot &cold water for cleaning <br />Y✓ Toilet & hand washing ❑Store refrigerated food <br />#o dry f d/suppl'° s ��Provide pot ble water <br />Overnight parking � Adequate electrical outlets <br />Si Lure of Com wne�r/®per-tor <br />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 <br />Date <br />