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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHICLE 9NFORMATIO <br /> Vehicle Name(DBA): <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: a ) �' 4) Year: 1� / <br /> 2) Vehicle Vin# 5) Make/Model: <br /> 3) State Decal 6) Color: G <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: 1441� GS OS— <br /> Street Address city <br /> F <br /> The mobile food facility shall operate out of a commissary and shalt report to the commissary at least once each <br /> i 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 of Vehicle Operator Date <br /> I COMMISSARY INFORMATION <br /> Business Name: oO� � <br /> Owner Name: <br /> Site Address: <br /> Street Address city <br /> � Phone: (ZCLl) te� <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> con, missary as checked below: <br /> Liquid&solid waste disposal Utensil washing sink c ❑Store frozen food )I' Vehicle wash facilities <br /> I (2 or compartments) i <br /> ❑ Preparation of food Hot&cold water for cleaning ©Toilet&hand washing 0 Store refrigerated food <br /> i <br /> ❑ St e dry fvodlsupplies Provide potable water Overnight parking Adequate electrical outlets <br /> I i <br /> c <br /> l Signature of Gomrfiissary Owner/0 rato �l Date <br /> 1 <br /> C E-ALTH DEPARTN9ENfT <br /> I If the commissary/food establishment is outside San Joaquin County,the local health jurisdiction must verifij <br /> current health Permit by signing below. Commissary/food establishment is in <br /> i <br /> I Signature of Count f REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/1812006 <br />