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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): ` L <br /> Address for Vehicle: ��� '- G��ZC C fes* <br /> Street Address City <br /> 1) License Plate#: ��, / 1 4) Year: <br /> 2) Vehicle Vingip 5) Make/Model: <br /> 3) State Decal#: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> G' <br /> Address of Owher: jFQZ,'� �� <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 fo 4,'ngd servicin {CalCode sections 114295 & 114297). If the use of the commissary is <br /> r 'dist My t is office to make the necessary changes. Failure to notify this <br /> discontinue , the r it ode <br /> office m resul p r t yevo ation a d pen ties. <br /> Si atu o Vehicle Op ato Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: , h <br /> Site Address: y <br /> Street Address <br /> !) I city <br /> Phone: (�� - t�S��� <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 /> z <br /> 25 Liquid&solid waste disposal Utensil washing sink ❑ Store <br /> (2 or 3 comparf rents) frozen food FAVehicle wash facilities <br /> ❑ Preparation of food Hot&cold water for cleaning Toilet&hand washing ❑ Store refrigerated food <br /> Ful <br /> ❑ Store dry food/suppliesProvide potable water 0 Overnight parking L <br /> pj Adequate electrical outlets <br /> vim _ c r�riz�c� Wte4 6, -3 - G <br /> Signature of Commissary Owner/010ator 1 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- 5 of <br /> 7/18/20088 MFPU APPLICATION <br />