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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): r k u <br /> Address for Vehicle: 02 O G 9 (�7, 5TH -51 S10 d fly C� <br /> Street Address city <br /> 1) License Plate#: h K S $ 4) Year: 02 <br /> 2) Vehicle Vin#: 5) Make/Model: Q L <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: TD,5E Z. OgttJcZ I- ( Mft" <br /> Address of Owner: O r7 kj(t S oC k C �S� 0 <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 nlay res ermit revocation and penalties. <br /> Si ature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: 66911061 j G u GJ1, C2-NT6W <br /> Owner Name: ���� p q 0 p <br /> Site Address: -y S' (,� 0ti) S , -5jlJ C79 X02 D<.' <br /> n Street Address city <br /> Phone: <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 /> 0 Liquid&solid waste disposal E Utensil washing sink <br /> (2 or 3 compartments) Store frozen food 0 VehiGe wash facilities <br /> Preparation of food [g/Hot&cold water for cleaning [�TToilet&hand washing Store refrigerated food <br /> ore dry food/suppliesrovide potable water D zOvemight parking [ Adequate electrical outlets <br /> c• <br /> r /0 <br /> Si nature of Commissa Owner/O erator 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 />