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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): —rMLA�2 01 1 IO <br /> Address for Vehicle: <br /> Street Address h+ <br /> h <br /> 1) License Plate#: 4W A % 4) Year: AO Z 7 <br /> + <br /> 2) Vehicle Vin #: C.9Qj// QG' 5) Make/Model: (; G <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address o Owner:/3 -11 J -d..., Z <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 perm' holder must notify this office to make the necessary changes. Failure to notify this <br /> office may resultiecdtio`n and penalties. <br /> 1 _ 105 ILI <br /> Si na u're of Vehicle Operator Date <br /> COMMISSARY INF RMATI N; r <br /> Business Name: ., <br /> Owner Name: + <br /> Site Address: <br /> Street Address City <br /> Phone: jr ) <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 M Utensil washing sink ❑ Store frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> ❑ Preparation of food of&cold water for cleaning X Toilet&hand washing ❑ Store refrigerated food <br /> ❑ Stor ry food/supplies Provide pota a water Overnight parking Adequate electrical outlets <br /> Signature of Commi ary Owner/Operator 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 /> 7/18/2008 <br />