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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: 7, ._ - -.J <br /> Street Address City <br /> 1) License Plate #: 4) Year: Gc%i5� <br /> ^) Vehicle Vin #: 5) Make/Model. �;;G ?,.c.�i� C-4—le,Z <br /> 3) State Decal #: fi/ €wD 6) Color: <br /> VEHICLE OWNER INFORMATION <br /> Name: ,• /.�E <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'n.peimit revocation and penalties. <br /> Signature o(Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: CAUFORK11Arx., <br /> Site Address: 7 G 5 �-/ yZ �; lr`-- -.T -- R�% <br /> Street Address i 94YIM S.AIRPORT WAY <br /> Phone: ( (� STOCKTON, CA 95206UUU <br /> , .. <br /> I, the commissary owner, can and will provide the necessary facilities for the above mentioned vefiic7e"atmy— <br /> commissary as checked below: <br /> Q Liquid &solid waste disposal Utensil washing sink <br /> (2 or 3 compartments) Store frozen food Q Vehicle wash facilities <br /> Q Preparation of food Q Hot&cold water for cleaning ©Toilet&hand washing 0 Store refrigerated food <br /> FJ' Store Store dry food/supplies ©Provide potable water Q Overnight 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 /> 7/F18/200817 ( f 1 �� �� �� MFPU APPLICATION <br />