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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 <br /> Address for Vehicle: % <br /> Street Address CRY ew <br /> 1) License Plate#: 4) Year: <br /> 2) Vehicle Vin#: 5) Make/Model: <br /> 3) State Decal#: c_ 6) Color: '�, <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address o wner. I �i 7ae a � � <br /> Street Address <br /> 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 114296 & 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 /> COMMISSARY INFORMATION <br /> Business Name: Lo, �. <br /> Owner Name: �` r <br /> Site Address: - , <br /> Street Address city <br /> Phone: Q �-1 -, i 5'� <br /> 1,the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> c <br /> ® Liquid&solid waste disposal '= utensil washing sink ❑Store frozen food Vehicle wash facilities <br /> (2 or 3 comparfinents) <br /> ❑ Preparation of food Hot&cold water for cleaning ®Toilet&hand washing ❑ Store refrigerated food <br /> red rood/su Ile �! <br /> ❑ dry PP. ®Provide potable water Overnight parking [ dequate electrical outlets <br /> 'Signature of Commissary Owner/0116rator <br /> a 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 /> EHO 10-017 5 of 6 <br /> 7118/2008 MFPU APPLICATION <br />