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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): + "j (' Q� <br /> Address for Vehicle: S23 LP \,-Icon -�, Gl Gl CA <br /> Street Address City <br /> 1) License Plate#: �;f --D 4) Year:Z2 <br /> 2) Vehicle Vin #: 5) Make/Model: <br /> 3) State Decal#: 6) Color: no ron <br /> VEHICLE OWNER INFORMATION <br /> Name: •6'n <� 1Lk , C <br /> Address of Owner: � , 6 W60133'42;14 <br /> Street Address Citq <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 /> Signature of Vehicle Operator ate <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: <br /> Street Address City <br /> Phone:AV ) 5y / 12S5 <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 /> squid&solid waste disposal [�TJtensc 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 /> ,✓'"jtgrre dry food/supplies [4'"1`5—rovide potable water [�Overnight parking ®Adequate electrical outlets <br /> Sigl ature of Commissary Owner/Operator Date <br /> HEALTH DEPARTMENT <br /> If the commissary/food establishment is outside San Joaquin County, the local h +alth jurisdiction must verify <br /> current health pe ning below. Commissary/food establishment is in S <br /> n y. <br /> Si nature of Cou ty EH Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />