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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): O <br /> Address for Vehicle: <br /> Street Address City <br /> "'��),�F.,F��3��q(3 - <br /> 1) License Plate#• �Rr 4) Year: <br /> 2) Vehicle Vin #: h 4M 4 5) Make/Model: " oo <br /> 3) State Decal* 6) Color: ( 1�p <br /> VEHICLE OWNER INFORMATION <br /> Name: <br /> Address of Owner: 2.0 I G. c J 7 D <br /> treet 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 /> ofrice r l la hermit revocation and penalties. <br /> Sir acture of Acle O erator Date <br /> COMMISSARY INFORMATION <br /> Business Name: <br /> Owner Name: Y yPj <br /> Site Address: S . <br /> Street Address city <br /> Phone: (2eelrs -4 -Ze—I 2= 1 17qJ <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 /> Liquid&solid waste disposal Utensil washing sink ❑ Store frozen food ehicle wash facilities <br /> (2 or 3 ompartments) <br /> Prep Ion of food Hot&cold.water for cleaning oilet and washing ❑ Stor efrigerated food <br /> Sto ry food/supplies rovide potable w ter Overnight parking Adequate electrical outlets <br /> I 4& <br /> Signature of Comm ssa Owner/O erator 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 16-017 5 of 6 MFPU APPLICATION <br /> 7/182008 <br />