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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 /> ti <br /> Address for Vehicle: �a CO 5 <br /> Street Address -city <br /> 1) License Plate#: % l p a L 4) Year: <br /> 2) Vehicle Vin#: %j ,/)J-t WTI Y#- & ,5c)/ 5) Make/Model: �d'7 <br /> 3) State Decal#: 6) Color: 11aZt� <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> ..� , <br /> Address of Own r: L <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 /> Signature ofehicle O e i Date <br /> COMMISSARY INFORM TION <br /> Business Name: <br /> CLQ <br /> Owner Name: <br /> Site Address: <br /> Street Address I City <br /> Phone: oc ) q(),(— 'N 7d <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 Store frozen food <br /> (2 or 3 compartments) ❑ Vehicle wash facilities <br /> ❑ Preparation of food 91 Hot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> ❑ St dry food/supplies � Provide potable water ❑ Overnight parking ❑Adequate electrical outlets <br /> Signature of Com ssary Owne erator 7 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 <br /> 7/18/2008 MFPU APPLICATION <br />