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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): �f%7 / <br /> Address for Vehicle: �f� r /�}-�,�!/>,�(> %1,' ��( reit CA <br /> Street Address City <br /> 1) License Plate#: � ~KKK `i O 4) Year: 1 <br /> 2) Vehicle Vin#: 5) Make/Model <br /> 3) State Decal #: 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: yid/f�L � <br /> Address of Owner: Z-? 5 L = l' P,�1((,I C-' -5(((jU <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 /> ,ice �7 <br /> CJ c� <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: : ( 7 J . t(i yL G� _� (^ 5 (C%CAJ 0, )0 -6 9, 5s.. <br /> /�� Street Address City <br /> Phone: ( ) =_��ter- 5 of(4—, <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 /> 0 2 or 3 compartments) <br /> Liquid&solid waste disposal �ltensc washing sink Store frozen food y Vehicle wash Facilities <br /> Preparation Of food �ot&cold water for cleaning 2/Toilet&hand washing L4A Store refrigerated food <br /> El-s'toredryfood/supplies 2-�Provide potable water 20vernight parking Adequate electrical outlets <br /> Signature of Commissary Owner/Operator 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 16-017 5 of 6 MFPU APPLICATION <br />