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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): a (In V Z° J (f <br /> Address for Vehicle: <br /> Street Address City 9 <br /> 1) License Plate#: ( PT231 '5 4) Year: / / 7? <br /> 2) Vehicle Vin#: �r P 17���aJ��P 5) Make/Model: T_ � <br /> 3) State Decal#: 6) Color: / <br /> VEHICLE OWNER It FORMATION <br /> Name: VV& �x <br /> Address of Owner: e <br /> Street Address I f 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 may result in permit revocation and penalties. <br /> /D o6 lS <br /> Signature of Vehicle Operator Dat <br /> COMMISSARY INF R AWN <br /> Business Name: Lg4m1ged I2 <br /> Owner Name: <br /> Site Address: LAG (�jj <br /> Street AddressaCj <br /> Phone: )Lo / /Z <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 /> ff"L'iquid&solid waste disposal Lh Utensil washing sink ❑ Store frozen food g�/Vehide wash facilities <br /> (2 or 3 compartments) <br /> Preparation of food ❑Hot&cold water for cleaning [�toilet&hand washing ❑ Store refrigerated food <br /> [Store dry ood/suppli s ['BJP ide potable water [Onvernight parking Adequate electrical outlets <br /> S nature of Commissa Ownertipefator 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 /> 7/1812008 <br />