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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: <br /> Street Address city <br /> 1) License Plate #: C)LO 1-15 02 4) Year: �d L <br /> 2) Vehicle Vin #: 146 'J z p 5233q/50y 5) Make/Model: ('''4VvV "ekadi�� <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION_ <br /> Name: C"767c <br /> Address of Owner: ] ( C <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 may result in permit revocation and penalties. <br /> Si nature of Vehicle O erator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: u <br /> Site Address: <br /> Street Address itY <br /> Phone: (' j�, ) <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 /> Liquid&solid waste disposal [] Utensil washing sink 0 Store frozen food ElVehicle wash facilities <br /> (2 or 3 compartments) <br /> RIPreparation of food 0 Hot&cold water for cleaning ®Toilet&hand washing Store refrigerated food <br /> Store dry food/supplies Provide potable water El Overnight parking E v dequate electrical outlets <br /> A-411 <br /> _r <br /> Si nat re of Coifimissary Owner/Operator D to <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. (:�m��SSGi fJ o�vr�✓ ��c GLLcG� 11Pc� i � iG c fYuGd� <br /> f• :Z S 1 c�� _ , tSG►�� C{�/ / f 9 <br /> Signature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />