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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all infi oration requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle, ' <br /> 5� 5 <br /> Street Kddress City <br /> 1) License Plate#: �`Sys , ` 4) Year: / / -7- <br /> 2) Vehicle Vin#: �Q >' �i,/��G'Q 5) Mace/Model: <br /> 3) State Decal#: - 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: 'f <br /> Address of Owner. f _ <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 resuit in permit,rpypcation and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: 0. 'A <br /> Site Address: <br /> Street Address <br /> Phone: city <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 <br /> (2 or 3 compartments) Stare frozen food Vehicle wash facilities <br /> Prepara ion of food 1,211- riot&cold water for cleaning -toilet&hand washing U Store refrigerated food <br /> tare ary food/supplies Provide potable water Overnight parking [,Adequate electrical outlets <br /> Signature of Commiissa Owner/O of or 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. Commissarylfood establishment is in <br /> County. <br /> Signature of County REHS Date <br /> EHD 16-017 5 of <br /> 7/18/2008 MFPU APPLICATION <br />