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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> ICLE INFORMATION <br /> ehicle Name (DBA): <br /> Address for Vehicle: �< ve <br /> Street Address City <br /> 1) License Plate#: / �1 /S P 1 4) Year: <br /> 2) Vehicle Vin#: f'lS~ //S �� 5) Make/Model: ,,- <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: /W, L�S� �� `I—CZZ��, , ti �7 <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 /> off'T may result' permit revocation and penalties. <br /> i tui-6 of VX"G'ie Operator Date <br /> COMMISSARY INFORMATI N <br /> Business Name: <br /> Owner Name: <br /> Site Address: <br /> Street Address city <br /> Phone: Q C ) <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 /> ® <br /> Liquid&solid waste disposal Utensil washing sink <br /> (2 or 3 compartments) ❑ Store frozen food Vehicle wash facilities <br /> ❑ Preparation of food Hot&cold water for cleaning ®Toilet&hand washing ❑ Store refrigerated food <br /> i <br /> ❑ Store dry food/supplies ® Provide potable water Overnight parking Adequate electrical outlets <br /> l C' <br /> Signature of Commissary 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 S of 6 MFPU APPLICATION <br /> 7/1812008 <br />