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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): all C'aAl <br /> Address for Vehicle: 02r9akll L <br /> Street Address n city <br /> 1) License Plate#: �4 � V n4) Year: <br /> 2) Vehicle vin #: [,C,4A 07- T!gfKAake/Model: 2 a', <br /> 3) State Decal M 6) Color: <br /> VEHICLE OVVIAER INFO ATIO <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 /> discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br /> office irrovesult in p rmit revocation and penalties. <br /> Skfhature of Vehicle Operator Date <br /> COMMISSARY INFORMA I N <br /> Business Name: I rCS p/f �Z v( / TSI <br /> Owner Name: 14 <br /> Site Address: (yz_ rA 17S� <br /> Street Address city <br /> Phone: ( D <br /> I,the commissary owner,can and will provide the necessary facilities for the above mentioned vehicle at my <br /> commi sary as checked below: <br /> Lisolid waste disposal Utensil washing sink Store fro n food Vehicle wash facilities <br /> (2 or J compartments) <br /> ;P�r'eu;at'ion of food of&wld water for cleaning oilet&hand washing Stor efngerated food <br /> food/supplies to ' ter te might parking Adequate electrical outlets <br /> Si nature missa Owner/O erator <br /> HEAL EPARTMENT <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 /> Cou ty: <br /> Signature Co ty RE HS Date <br /> EHD 1M17 506 MFPU APPLICATION <br /> 7/18/2008 <br />