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ocr c. <br /> 14 Rd <br /> ai, 953o VERIFICATION OF VEHICLE COMMISSARY <br /> 20963 <br /> _ _ lease provide all information requested. An incomplete application may delay approval. <br /> VEHICLE INFORMATION <br /> Vehicle Name (DBA): <br /> Address for Vehicle: (fa 3C, 6_ <br /> — G d, P G 'D <br /> Street Address City <br /> 1) License Plate #: 4) Year: <br /> 2) Vehicle Vin #: 5) Make/Model: <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: 1� rl�C' �J�- ► �� <br /> Address of Owne : y� <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 result in permit revocation and penalties. <br /> Si nature of Vehicle Operator Date <br /> COMMISSARY INFORMATION, <br /> Business Name: <br /> Owner Name: •Z;Y �` . '?")!` ! - �� p <br /> Site Address: !ct/ � l v �Cd <br /> Street Address City <br /> Phone: (..L,�l,) �l_ :)-DD 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 /> ❑ Liquid&solid waste disposal El Utensil washing sink <br /> (2 or 3 compartments) ❑Store frozen food ❑ Vehicle wash facilities <br /> ❑ Preparation of food ❑ Hot&cold water for cleaning E]-Toilet&hand washing Q Store refrigerated food <br /> Store dry food/supplies ❑Provide potable water ❑Overnight parking ❑Adequate electrical outlets <br /> Al /4y <br /> Signature of Commissary Owner/Operators�' ¢;,: F',;:,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. VV <br /> Sig—nature of County REHS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />