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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): S <br /> Address for Vehicle: 2ygo -C r r n rA- qrj <br /> Street Address city <br /> 1) License Plate#: y Y5317;1Z 4) Year: 19 W/ <br /> 2) Vehicle Vin#: � ,0/ KdJSS0W;bl 5) Make/Model: (fb evale f <br /> 3) State Decal#: ('4 6) Color: IUt<1iIQ <br /> VEHICLE OWNER INFORMATION <br /> Name: beetC1irCi(:� <br /> Address of Owner: 3O V' <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 /> o�ayresulermitrevocation and penalties. <br /> /—/"1-4 <br /> S nature of Vehlc e Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: Por <br /> Owner Name: k �r <br /> Site Address: 9k) S C. V, <br /> Street Address City <br /> Phone: V01 ) 2-7-1— 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 /> L �tensil washing sinkiquid&solid waste disposal or 3 compartments) Store frozen food Vehicle wash facilities <br /> reparation of food F;Hot&cold water for cleaning EI/Toilet&hand washing 19- Store refrigerated food <br /> D/Store dry food/supplies BProvide potable water [J Overnight parking W Adequate electrical outlets <br /> �iqnrure of Commis wner/0 erator Datef <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 /> EHC 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />