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VERIFICATION OF VEHICLE COMMISSARY <br /> Please provide all information requested. An incomplete application may delay approval. <br /> VEHIGLE.INFORMATION_ <br /> Vehicle Name (DBA): DAMPt 1j <br /> Address for Vehicle: 730 <br /> street Address City <br /> 1) License Plate#: 4IF7F 7,20.3 4) Yea(�r:: a cc)to <br /> 2) Vehicle Vin #: 1.��flTdS/7�{�I oVa /Model: 1114fl61 <br /> 3) State Decal #: 6) Color: 10L"—) <br /> VEHIC OWNER INFORMATION <br /> Name: <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 /> disc 'nued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> offi a ay e n permit revoc ion and penalties. <br /> Signature of Vehicle Operator Date <br /> COMMISSARY INFORMAT ON <br /> Business Name: <br /> Owner Name: Ady 9t (pNy <br /> Site Address: 1Gt , 5 � <br /> Street Address City <br /> Phone: (prl 14(' Q <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 /> uid&solid waste disposal nsil washing sink El Store frozen food ehicle wash facilities <br /> (2 or 3 compartments) <br /> reparation of food ;�ro<vide <br /> ter for cleaning et&hand washing ❑ Store refrigerated food <br /> t e dry food/s plies le water ernight parking equate electrical outlets <br /> Signature of Commissa 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 /> EHD 16-017 5 of 6 MFPU APPLICATION <br /> 7/18/2008 <br />