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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: ,ice c <br /> StreetAddress city <br /> 1) License Plate#: I /5317 4) Year: /V 8c� <br /> 2) Vehicle Vin#: :t6jdH93 Ko:JSSt0 ? /5) Make/Model: tZ male _ <br /> 3) State Decal#: 04 6) Color: whoa <br /> VEHICLE OWNER INFORMATION <br /> Name: Lewd 60601 <br /> Address of Owner: 3a 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 114296 & 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 ay result in ermit revocation and penalties. <br /> S' nature of Vehicle Operator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: y <br /> Site Address: <br /> Street Address city <br /> Phone: (Z01 ) 27-7-1— y <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 sink quid&solid waste disposal or 3 compartments) Store frozen food Vehicle wash facilities <br /> reparation of food Wmot&cold water for cleaning EI Toilet&hand washing B//tore refrigerated food <br /> Store dry food/supplies sProvide potable water [5/overnight parking W Adequate electrical outlets <br /> S'g ure of Comm iss wner/O perator Dat <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 o1`6 MFPU APPLICATION <br /> 7/1812008 <br />