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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): <br /> Address for Vehicle: /3 O T6 HVIA14 OAK, X 7-5-3�, 6 <br /> Street Address City <br /> 1) License Plate #: -((} 4) Year: © 15 <br /> 2) Vehicle Vin #: 5) Make/Model: 150 S 0 <br /> 3) State Decal #: 6) Color: �Lol�l <br /> VEHICLE OWNER INFORMATION <br /> Name: J-6 V I C-9 NG S -- <br /> Address of Owner: 1,3 G < (O(O F1 fi PON A DA 1%t P,5-,3 6 6 -- <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 /> ice may result in per it revocation and penalties. <br /> 13 /5/0 <br /> tygnature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: UAf V (5 fi€)� //Zi�G 7—A'0 6 Jc: C Civ-t"6 A- <br /> Owner Name: Tcf-'t 1 f p T R AO <br /> Site Address: 1 7 1 *7 _ uNf OJ J �5 T 51 ©C kl o ftl (fl? <br /> Street Address City <br /> Phone: (xC8) -e 5 - <br /> 1,the commissary owner, can and will provide the necessary facilities[or the above mentioned vehicle at my <br /> commissary as checked below: <br /> Liquid&solid waste disposal LjjUtensil washing sink dStore frozen food Vehicle wash facilities <br /> (2 or 3 compartments) <br /> Q115reparation of food L2 Not&cold water for cleaning Toilet&hand washing dStore refrigerated food <br /> tore dry food/supplies Provide potable water E Ovemi t par ing Adequate electrical outlets <br /> Si nature of Commissary Own r/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 RENS Date <br /> EHD 16-017 5 of 6 MFPU APPLICATION <br />