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rr <br /> VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An Incomplete application may delay approval <br /> VEHICLE-INFORMATION. s <br /> Vehicle Name(DBA): 1 <br /> Address for Vehicle: <br /> Street Address city <br /> 1) License Plate#: /�/L j� �51� � 4 Year: <br /> 2) Vehicle Vin #: j7,L�ygMake/Model: tl <br /> 3) State Decal #: 6) Color: F <br /> NEHICLE OWNER-.INFORMATION. <br /> F Y. <br /> Name: <br /> Address of Owner: �y L <br /> Stre t Address city <br /> The mobile food facility shall operate out of a commissary and shall report to the commissary at,least once <br /> each operating day for cle ing and servicing (CalCode sections 114295 & 114297). If the use of the <br /> commis is discontinue a permit holder must notify this office to make the necessary changes. Failure <br /> to noti ffice may in permit revocation and penalties. <br /> Si lure ol Vehicle O erat r 7/�9/i/ <br /> Date <br /> (COMMISSARY INFORMATION - - -- <br /> Business Name: Z2 <br /> Owner Name: <br /> Site Address: / .` -71 S -,3' <br /> Street Address City <br /> Phone: 2-711 <br /> j <br /> 1,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commissary as checked below: <br /> Liquid&solid waste disposal Utensil washing sink <br /> (e compartment sink( ❑Store frozen food Vehicle wash facilities <br /> Preparation of food Hot&cold water for cleaning t���Toilet&hand washing TTT❑"""Store refrigerated food <br /> 174 Stor dry food/supplies Provide potable water LgOvernight parking i Adequate electrical outlets <br /> SI nature of Commissa Owner/O e_ra_tor Date <br /> -- . -'- <br /> iWEALTH DEPARTMENT ` � -- - <br /> i <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 R EHS Date <br /> EHD 16-013 Page 8 of 9 <br /> 7/28/2010 MFF APPLICATION <br />