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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: �/ C!� <br /> Street Address City <br /> 1) License Plate #-. yi��3/`�� 4) Year: 1�r� <br /> 2) Vehicle Vin #: C'q/jlsy�8 5) Make/Model: <br /> 3) State Decal #: 6) Color: �� <br /> VEHICLE OWNER INFORMATIO <br /> Name: <br /> Address of Owner: <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 /> r-- - /2 - /- Zo�y <br /> Si nature o Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: <br /> Site Address: .2.14 C4-0 119-4}Q_ p If �`r�� � � - -y _ <br /> Street Address (04110 S.AIRPORT WAY <br /> Phone: ( ` 1 STOCKTON, CA 95206 <br /> -- 91300S <br /> I,the commissary owner, can and will provide the necessary facilities for the above mentioned"vehicle atmy— <br /> commissary as checked below: <br /> Liquid&solid waste disposal El Utensil washing sink <br /> (2 or 3 compartments) Store frozen food 0 Vehicle wash facilities <br /> E-lPreparation of food 0 Hot&cold water for cleaning 0 Toilet&hand washing © Store refrigerated food <br /> ElStore dry food/supplies E21provide potable water 52 Overnight parking Adequate electrical outlets <br /> 1-71 <br /> Signature of Commi sary 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 17 <br /> 7/18/2008 C �� Fit P_� �/�� N 1A MFPU APPLICATION <br />